COLLEGE  OF  OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


UNIVERSITY  OF  CALIFORNIA 
"VJFORPIIA  COLLEGE  OF  MEClC 


APR  2  7  19T3 
CAUFCRNIA  92667 


^^  • 

ORIFICIAL 

L_ 


UER£FY  OF 
E  OF 


ITS 


Philosophy  Application 
am/  Technique  ^ 


Compiled  and  Edited 

by 

B.  E.  DAWSON,  M.  D. 

Kansas  City,  Mo. 


Assisted  by 

ELIZABETH  H.  MUNCIE,  M.  D.,         A.  B.  GRANT,  M.  DM 
and  H.  E.  BEEBE,  M.  D. 


Authorized  by  The  American  Association  of  Orificial  Surgeons 


Published  by  the 

PHYSICIANS  DRUG  NEWS  CO. 

NEWARK,  N.  J. 


1(2- 


COPYRIGHT  1912 

By 

PHYSICIANS  DRUG  NEWS  CO. 
NEWARK,  N.  J. 


Preface. 


"Instead  of  condemning  me  to  death  the  city  (Athens) 
should  grant  me  a  pension." — Socrates. 

A  word  of  explanation  is  due  the  reader  as  to  the  origin 
of  this  book.  For  several  years  I  have  been  an  enthusiastic 
disciple  of  Dr.  E.  H.  Pratt,  and  have  written  numerous  articles 
for  various  medical  journals  and  read  papers  before  medical 
societies  on  the  subject  of  Orificial  Surgery.  About  one  year 
since  I  was  solicited  by  a  number  of  individuals,  some  I  had 
never  seen,  to  write  a  book  on  this  subject  as  there  is  none 
extant.  I  strongly  demurred  until  these  requests  became  so 
urgent  that  I  consented  to  compile  a  small  book  and  solicited 
the  assistance  of  other  orificialists. 

At  the  request  of  Dr.  Elizabeth  H.  Muneie,  of  Brooklyn, 
I  held  in  abeyance  my  plans  until  the  next  meeting  of  the 
American  Association  of  Orificial  Surgeons.  At  that  meeting 
Dr.  Pratt,  Dr.  Muneie  and  I  held  a  conference  and  agreed  on 
the  plan  that  produced  this  book.  Dr.  Muneie,  who  was  then 
president  of  the  Association,  recommended  it  in  her  "presi- 
dent's address,"  and  the  Association  authorized  it  by  unani- 
mous vote.  The  plan  was  to  compile  the  book  from  material 
to  be  selected  from  The  Journal  of  Orificial  Surgery,  edited 
by  Dr.  Pratt  several  years  ago,  and  also  from  the  year  books, 
reporting  Dr.  Pratt 's  clinics.  I  was  appointed  editor,  and  Drs. 
Elizabeth  H.  Muneie,  A.  B.  Grant  and  H.  E.  Beebe  were  ap- 
pointed on  a  committee  to  assist  in  selecting  the  material. 

This  material  was  gleaned  from  a  vast  amount  of  litera- 
ture and  amply  covers  the  field  for  the  purpose  of  this  volume. 
Much  that  is  most  excellent  had  to  be  left  out  for  want  of 
space.  There  are  some  repetitions,  but  of  such  importance  as 
to  need  this  emphasis. 


o 


iv  PREFACE. 

The  reader  will  bear  in  mind  that  some  chapters  were 
written  several  years  since,  and  may  require  a  retrospective 
interpretation  of  chronological  statements,  though  I  have  taken 
the  liberty  of  revising  most  of  these  statements.  I  have  also 
taken  the  liberty  to  eliminate  portions  of  articles  not  germane 
in  book  form.  Many  reports  of  cases  were  forced  out  to 
give  room  to  matter  more  directly  setting  forth  the  Orifieial 
Thought.  The  classifying  of  this  material  was  often  perplex- 
ing; not  being  written  for  book  form,  some  articles  dealt  with 
more  than  one  subject  but  could  not  be  divided. 

Much  space  is  given  to  the  Philosophy  of  Orifieial  Surgery 
and  also  to  the  Rectum.  This  is  for  two  reasons:  first,  on  ac- 
count of  their  value  and  prominence  in  the  inventory ;  second, 
because  there  was  so  large  an  amount  of  material  on  these 
subjects  that  was  so  excellently  practical  as  to  forbid  curtail- 
ment. The  medication  prescribed  might  have  been  cut  out, 
and  in  many  cases  was,  but  some  times  left  as  helpful  to  those 
who  wish  it. 

As  editor  I  have  had  but  little  to  write  as  the  field  is  so 
well  covered.  I  have  eliminated  and  made  some  changes,  and 
here  and  there  sandwiched  in  a  few  lines,  designated  to  show 
the  responsibility. 

I  wish  to  heartily  thank  our  beloved  Dr.  Pratt,  for  his 
help  and  encouragement,  also  my  assistants  and  all  others  who 
have  encouraged  me  in  the  work.  It  has  been  a  labor  of  love 
as  well  as  helpfulness  to  me  in  a  reflex  way.  It  affords  me 
much  pleasure  to  launch  this  volume  freighted  with  a  cargo 
of  commjodities  to  bless  humanity.  May  it  be  received  and 
utilized  with  the  same  earnest  desire  that  prompted  its  launch- 
ing: that  of  doing  good  in  helping  others. 

B.  E.  Dawson,  M.  D., 

3220  Oak  Street. 


E.   H.   PRATT,   M.   D. 


Orificial  surgery  no  longer  needs  individual  indorsement. 
Its  principles  are  indelibly  etched  into  medical  history,  and 
its  establishment  has  now  become  extensively  accomplished 
and  will  unquestionably  mark  an  era  in  medical  practice.  It 
no  longer  needs  individual  support  or  indorsement,  as  its 
growth,  appreciation,  and  prominence  are  already  assured. 
There  is  no  longer  the  slightest  danger  that  orificial  surgery 
will  be  either  ignored,  forgotten,  or  neglected  by  the  medical 
world  or  its  patrons.  Much  progress  has  been  made  in  its  meth- 
ods and  there  is  still  room  for  more ;  but  the  foundation  prin- 
ciples have  never  changed  since  their  first  enunciation ;  nor  can 
they  ever  change,  because  they  are  so  consistent  with  what  is 
already  known  of  the  structure  and  vital  processes  of  every 
human  being. 

Slowly,  by  degrees,  the  profession  are  awakening  to  the 
all-important  fact  that  there  is  but  one  central  idea  in  medical 
practice,  and  that  is  the  circulation  of  the  blood.  By  this 
single  process  has  all  growth  been  accomplished,  and  by  this 
same  process  must  all  repairs  be  made.  Consequently,  remedial 
measures  are  valuable  only  as  they  act  upon  the  circulation, 
either  locally  or  generally.  Just  in  proportion  as  this  con- 
ception has  secured  recognition,  to  a  corresponding  degree 
has  the  profession  been  liberalized,  so  that  it  now  contains 
large  numbers  of  ardent  truth-seekers,  who  are  earnestly 
making  the  acquaintance  of  every  available  means  by  which 
the  blood-stream  can  be  fluctuated  and  controlled.  Prejudice 
is  melting  away,  hostilities  to  innovations  are  becoming  en- 
feebled, all  hindrances  to  progress  are  being  torn  down,  the 
tyranny  of  ignorance  and  conceit  is  being  rapidly  overcome, 
and  never  before  in  its  history  has  there  been  such  a  whole- 
some and  widespread  awakening  and  friendliness  in  the  hearts 


vi  INTRODUCTION. 

of  medical  men  to  every  new  idea  that  can  demonstrate  its 
ability  to  flush  or  pale  bodily  tissues.  Drugs  and  knives  and 
local  applications  no  longer  constitute  a  complete  medical 
armamentarium.  The  part  which  mental  and  emotional  forces 
play,  not  only  in  the  functional  activity  of  all  bodily  organs, 
but  also  in  pathological  formations,  is  at  last  being  recognized 
by  medical  leaders,  and  also  to  a  considerable  extent  by  the 
rank  and  file  of  the  profession ;  and  a  knowledge  of  suggestive 
therapeutics  will  soon  become  a  necessary  part  of  a  complete 
medical  education.  The  value  of  osteopathy  as  a  remedial 
agent  will  in  due  time  be  recognized,  and  no  doubt  many  other 
forces  as  yet  unheralded  are  to  be  recognized  and  secure  a 
recognition  as  legitimate  means  of  cure  in  the  new  book  of 
progressive  medicine  which  the  first  end  of  the  twentieth 
century  is  rapidly  compiling. 

The  reason  why  orificial  surgery  has  gained  so  rapid  and 
complete  a  victory  against  the  bigotry  and  intolerance  of  the 
ignorance  which  first  opposed  it,  is  because-  it  speedily  dem- 
onstrated its  ability  to  stimulate  the  nutrition,  and  thereby 
influence  the  functions  and  conditions  of  the  entire  body  and 
all  its  parts.  Its  growth  has  been  phenomenal,  and  an  ig- 
norance of  its  principles  of  operation  and  neglect  of  their 
employment  in  proper  cases  is  rapidly  becoming  a  medical 
disgrace. 

Orificial  surgery  is  not  hostile  to  any  other  remedial 
measure  in  medicine,  but  the  doctor's  quiver  is  by  no  means 
too  full  of  arrows.  His  armanentarium  is  not  any  too  well 
stocked  with  remedial  measures.  We  are  striving  to  add 
another  arrow,  another  remedy,  and  we  present  it  to  the 
fraternity  with  an  abiding  faith  in  its  reliability  and  truth- 
fulness. The  good  which  can  be  accomplished  by  all  remedial 
measures  familiar  to  doctors  is  little  enough,  and  if  orificial 
surgery  shall  be  the  means  of  lessening  the  amount  of  suf- 
fering in  the  world  to  only  a  slight  degree,  our  enterprise 
will  have  served  a  worthy  purpose.  The  philisophy  of  orificial 
surgery  is  so  thoroughly  grounded  in  anatomical  and  physio- 


INTRODUCTION.  vii 

logical  facts  and  principles  that  we  feel  confident  that  it  must 
in  time  become  recognized  universally  as  sound  and  practical 
and  a  well-taken  step  of  pronounced  progress  in  the  history 
of  medicine.  The  methods,  however,  which  we  have  at  pres- 
ent to  present,  are  oftentimes  severe  and  objectionable  in 
many  ways,  and  therefore  may  be  shortlived,  being  superseded 
by  kindlier  and  more  effective  ones.  We  are  wedded  to  no 
practices  that  we  would  not  willingly  abandon  for  better 
ones  and  will  be  grateful  for  suggestions  of  improvements. 
It  is  wonderful  that  you  can  take  a  person  with  asthma 
and  in  fifteen  minutes  stop  it;  take  a  case  of  chronic  rheuma- 
tism, with  the  joints  all  swollen  and  full  of  pain  and  have 
the  pain  stop  and  the  patient  immediately  get  better  before 
the  sun  goes  down.  The  physical  accomplishment  of  orificial 
work  is  simply  beyond  our  appreciation.  As  I  stop  to  think 
of  things  I  have  seen  done  by  that  work  I  stand  dumfounded. 
I  am  surprised  that  it  is  not  appreciated  more,  but  it  is  because 
it  is  so  big.  If  it  were  only  a  cure  for  rheumatism,  it  would 
be  widely  known;  if  it  were  good  to  cure  only  dyspepsia,  if 
it  were  only  to  cure  paralysis  there  would  be  a  great  move 
among  paralytics  for  the  work.  If  it  would  cure  only  the 
insane  it  would  be  used  in  insane  asylums,  but  when  you 
claim  that  a  measure  is  a  measure  that  is  needed  in  all  cases, 
it  is  so  big  it  knocks  other  big  things  down.  It  asks  other 
measures  to  step  aside  and  let  it  in  to  lay  the  foundation. 
It  is  such  a  conceited  proposition  that  it  is  denied  a  hearing — 
but  it  is  going  to  be  heard,  and  its  wonderful  work. 


Contents. 


Chapter  Page 

I.     The  Birth   of   Orificial   Surgery 17 

II.  A  Brief  Chapter  in  the  History  of  Orificial  Surgery. .  26 

HI.  Orificial  Surgery:    What  is  it — Fact,  Fad   or  Fancy?.  .  39 

IV.     A    Plea    for   Orificial    Surgery 46 

V.     Orificial    Surgery    55 

VI.     Orificial    Surgery    61 

VII.     A    Synopsis    of    Orificial    Surgery    and    What    It    Has 

Achieved,  with  a  Eeport  of   Cases 72 

VIII.     Orificial  Surgery  and   the   General   Practitioner 82 

IXs    The  Composite  Physiological  Man 87 

X.     The  Mutual   Relations  and   Separate  Functions    of   the 

Two  Nervous  Systems    92 

XI.  Some  Points  in  the  Manner  of  Nerve  Distribution, 
Some  Characteristics  of  the  Sympathetic  Nerve  and 
the  Meaning  of  the  Term  Orificial 101 

XII.  The  Philosophy  of  "Nutrition"  and  the  Relation  of 
its  Disturbances  to  Affections  of  the  Nervous  System, 
and  the  Value  of  Orificial  Treatment  Therein 110 

XIII.  The  Orificial  Philosophy  and  Its  'Methods 114 

XIV.  Science  of  Orificopathy — or  Orificial  Methods  of  Cure..  120 
XV.     Orificial    Philosophy    122 

XVI.     Vasomotor  Centres    129 

XVII.  The  Sympathetic  Nervous  System — or  why  Orificial  Sur- 
gery Should  Cure  or  Affect  Most  Chronic  Diseases, 
Explained  from  an  Anatomical  and  Physological  Basis  133 


x  CONTENTS. 

Chapter  Page 

XVIII.     Reflexes  141 

XIX.     Reflex  Neuroses    153 

XX.     Orifieial    Reflexes   Clinically   Illustrated 1.1.1 

XXI.  Necessity  of  Considering  the  Reflexes  in  Making  Diag- 
noses     160 

XXII.     The    Technique   of   Crificial    Surgery 165 

XXI1L     Surgical    Judgment    171 

XXIV.  Orifieial     Surgery — Its     Dangers     and     Possibilities — A 

Preventive   Measure    173 

XXV.  A  Consideration  of  Orifieial  Methods  and  Operations.  .181 

XXVI.     Orifieial   Suggestions    106 

XXVII.     The    Confirmation    of    Experience 202 

XXVIIL     Surgical  Duties  of  the  General  Practitioner 211 

XXIX.     Nerve   Impingement   in   Operative   Surgery 216 

XXX.  Abdominal  Section  in  the  Light  of  Orifieial  Philosophy  229 

XXXI.     Neuroses  of  the  Rectum  and  Anus 237 

XXXII.  Rectal   Surgery   Considered    in   Its   Relation   to   General 

Surgery    242 

XXXIII.     The  Toilet  of  the   Rectum 247 

XXXIV.  A  Few  Points  on  the  Anatomy  and  Physiology  of  the 

Rectum — Pockets   and  Papillae    250 

XXXV.     Rectal  Surgery  from  an  Orifieial  Standpoint 281 

XXXVI.     Hemorrhoids    293 

XXXVII.     The  Slit  Operation    306 

XXXVIII.     The  Slit   Operation   Under  Cocaine 311 

XXXIX.     The   Treatment   of   Hemorrhoids 312 

XL.     The   American   Operation    in   Hemorrhoids 318 

XLI.     The  American   Operation    320 

XL1I.  Rectal    Diseases— Pistulae    .                                                   ..328 


CONTENTS.  xi 

Chapter  Page 

XLIII.     Strictures  and  Ulcers  of  the  Rectum 33t> 

XLIV.     Fistulae-in-Ano     345 

XLV.     Rectal   Fissures    361 

XLVI.     Diseases  of  the   Rectum  and  Sigmoid 365 

XL VII.     Sigmoid   Catarrh   in   Women 369 

XL VIII.     The    Sigmoid    372 

XLIX.  Non-Malignant  Diseases  of  the  Upper  Rectal  Pouch 
and  Sigmoid  Flexure,  and  an  Improved  Method  of 
Treatment  380 

L.     Some   Points  Concerning   the   Anatomy   and   Physiology 

of  the   Male   Sexual   Organs 387 

LI.     Circumcision    392 

LIT.     Circumcision    401 

LIII.     Lesions  Arising  from  Contracted  Prepuce — Twenty  Con- 
secutive Illustrative   Cases    404 

LIV.     The   Male  Meatus  and  Urethra 407 

LV.     The  Use  of  Male   Sounds 412 

LVI.     Diseases  of   the  Prostate 418 

LVLT.     Some   Points   Concerning   the   Anatomy  and   Physiology 

of  the  Female  Organs    431 

LVI1I.  Terminal  Nerves  of  the  Sympathetic  and  their  Troubles 
as  a  Factor  in  Pelvic  Inflammations  and  Other  Dis- 
orders of  Women  444 

LIX.     Dilatation  of  the  Vulva,  Vagina  and  Uterus 454 

LX.     The  Cervix  Uteri   461 

LXI.     Improved   Technique   in    Vaginal   Hysterectomy 466 

LXII.     Vaginal   Hysterectomy    474 

LXIII.  Circumcision   of  Girls    .                                                            ..482 


xii  CONTENTS. 

Chapter  Page 

LXIV.     Preputial    Adhesions   in   Little   Girls 491 

LXV.     Gynaecological  Keflexes   495 

LXVL  Improved  Method  for  the  Bepair  of  Complete  Lacera- 
tion of  the  Perineum    499 

LXVII.     The  Psychic  Factor   505 

LXVI1I.     Mental  Healing 529 

LXIX.  Suggestive   Therapeutics   ir,   the    Treatment   of  Chronic 

Cases;   or  as  an  Aide  to  Orificial  Surgery 543 

LXX.     Lowered  Vitality   551 

LXXI.  Functional    (Disturbances    and    Mental     Conditions    In 

Chronic   Diseases    555 

LXX1I.     Insomnia— Its  Relief  by  Orificial  Methods 566 

LXXIII.     Functional    Insanity    568 

LXXIV.     Neurasthenia    575 

LXXV.     Chronic  Constipation    578 

LXXVI.  Constipation   and   Diarrhea   as  a   Neurosis  —  Treatment 

from  an   Orificial  Standpoint 581 

LXXVH.     Constipation    584 

LXXVIII.     Epilepsy  Treated  Officially   586 

LXXIX.     Acne  Simplex  in  Young  Men 591 

LXXX.     Sympathetic   Vomiting   593 

LXXXI.     Hiccough  Cured    595 

LXXXIL     Sexual   Habits  and   Necessities 601 

LXXXI1I.     Tissue   Reading   from   an   Orificial    Standpoint 612 

LXXXIV.     Prostates  and  Wombs    619 

LXXXV.  Importance  of   After-treatment   in   Orificial   Surgery.  .  .625 

LXXXVI.     After-Care    627 

LXXXV1I.     After-treatment    in    Orifieial    Surgery 629 

LXXXVIII.     Some  After-thoughts,  Warnings  and   Helpful   Hints 645 


Contributors. 


Appleton,    T.    J 247 

Beebe,  Curtis  M 171 

Beebe,  H.  E 551 

Bessey,  AV.  E n  • 

Bliem,   M.   J 82 

Brown,  S.  G.  A 155 

Chancy,  E.  N 361 

Cogswell,   G.    E 372 

Cole,  E.  Z 280,  627 

Costain,  T.  E 328,  401,  578 

Dawson,  Benj.  E 46,  548,  574,  584,  631,  640,  645 

Eaton,  Cora  Smith   306,  311,  369 

Eldridge,  C.  S 165 

Green,   W.    E 499 

Grosvenor,  L.  C 466 

Holbrook,  Francis  D 474,  629 

Hood,  C.  T 543 

Hubbell,  Eug 120,  318,  586 

Hurt,  W.  H 593 

Means,  J.  W 129,  404,  581 

Morley,  F.  W 619 

Muncie,  Elizabeth  H 39,  72,  491 

Notrebe,  E.  P 135,  555 

Pauly,  C.  A 312,  365 

Pratt,   Leonard    46 

Pratt,  E.  H 17,  26,  87,  92,  101,  114,  173,  181,  196,  211,  216, 

229,  242,  250,  281,  293,  320,  335,  345,  387,  392,  407,  412,  418, 

431,  444,  454,  461,  466,  482,  505,  529,  595,  601,  612 

Reddish,   A.    W 153 

Eeplogle,  P.  S 160 

Runnels,  A.  M 61 

Runnels,  M.  T 495 

Sawyer,  C.  E 122,  202,  575 

Sherwood,  H.  A 625 

Skiles,  H.  P 568 

Townsend,  H.  L 237 

Weirick,  C.  A .  .141 


SECTION  I. 


General  View  of  the 
Orificial  Thought. 


CHAPTER  I. 
THE    BIRTH    OF    ORIFICIAL    SURGERY. 


E.   H.   PRATT,   M.   D. 


The  occasion  of  its  delivery  was  marked  by  a  peculiar 
combination  of  circumstances.  It  was  in  February,  near  the 
close  of  the  winter  term,  in  the  Chicago  Homeopathic  Medical 
College  in  the  year  1886.  The  class  had  had  a  hard  winter 
and  were  much  fatigued  and  many  of  them  ill.  The  surgical 
clinic  had  been  a  heavy  one  and  was  replete  with  illustrations 
of  the  connection  between  orificial  irritation  and  chronic 
general  conditions,  and  at  the  close  of  the  clinic  just  preceding 
the  delivery  of  the  lecture  we  are  about  to  publish,  the  nature 
and  scope  of  the  orificial  philosophy,  which  before  had  been 
but  fragmentary  in  its  manifestation,  dawned  upon  the  writer 
in  such  intensity  and  fullness  of  conception  as  to  leave  the 
class  at  the  close  of  the  clinic  with  the  impression  that  some- 
thing had  happened.  It  was  announced  that  the  next  lecture 
would  be  "A  Surgical  Talk  upon  the  Orifices  of  the  Body." 
The  circumstance  had  been  noised  about  to  some  extent,  so 
that  when  the  lecturer  arrived  the  audience  chamber  was 
crowded  to  its  capacity.  Fortunately  he  had  been  solicited 
as  a  member  of  the  faculty  to  contribute  an  article  to  the 
Medical  Era,  and  as  he  was  not  at  that  time  in  the  habit  of 
writing  and  consequently  had  delayed  complying  with  the 
request,  and  as  the  subject  to  be  presented  was  an  entirely 
new  one,  he  concluded  to  employ  a  stenographer  to  chronicle 
the  truths  he  was  about  to  present,  and  in  this  way  accom- 
plish two  purposes,  fulfilling  his  promise  to  the  Medical  Era 
to  furnish  it  an  article,  and  at  the  same  time  preserve  a  record 
of  his  first  expression  of  the  orificial  thought,  which  he  imme- 
diately conceived  was  destined  to  occupy  a  prominent  position 
in  medical  knowledge  and  literature.  To  that  end  Dr.  W.  S. 


18  OEIFICIAL  SURGERY. 

Moffatt,  at  that  time  of  Wheaton,  who  was  a  professional 
stenographer,  was  engaged  to  attend  the  lecture  and  report 
it.  But  for  the  promise  of  an  article  to  the  Medical  Era,  in 
all  probability  no  published  record  would  now  exist  of  this 
birth  of  a  new  medical  idea. 

We  believe  that  neither  ourselves  nor  any  person  present 
at  that  hour  will  ever  forget  the  occasion.  As  for  ourselves, 
our  feeling  of  depression  was  extreme,  and  if  the  stenographer 
had  not  been  engaged  to  be  present  and  the  announcement 
made  that  something  unusual  was  to  take  place,  we  would 
have  invented  some  excuse  to  escape  that  talk  at  the  college. 
But  duty  and  a  sense  of  honor  whipped  us  into  the  rostrum 
and  ushered  us  into  the  most  remarkable  hour's  experience 
which  our  lives  had  thus  far  known.  Our  talk  for  the  first 
ten  minutes  was  heavy,  laborious,  every  word  of  it  forced. 
The  extreme  position  we  were  placed  in  had  already  begun 
to  dawn  upon  us,  for  if  what  we  were  about  to  say  were  true 
it  was  such  an  innovation  in  the  practice  of  medicine  as  to 
completely  ostracize  us  from  the  medical  profession,  and  would 
necessitate  our  demonstrating  speedily  the  correctness  of  our 
position,  or  demand  our  withdrawal  from  the  institution  with 
which  we  were  connected,  and  probably  from  the  State  So- 
ciety, the  American  Institute,  and  in  all  probability  from  the 
practice  of  medicine.  So  the  issue  as  it  presented  itself  to 
our  mind  in  that  moment  of  exalted  preception  was  a  question 
of  professional  life  or  death.  Under  some  circumstances  one 
could  be  forced  to  the  edge  of  a  precipice  by  some  extreme 
danger,  where  the  only  safety  lay  in  a  superhuman  leap  to 
some  secure  resting  ground  beyond.  This  first  ten  minutes 
was  like  the  poise  on  such  a  brink.  "We  had  gone  too  far  to 
recede,  and  we  had  such  faith  in  the  vision  that  we  determined 
to  stand  by  the  courage  of  our  convictions.  We  realized 
fully  the  peril  of  the  position  we  were  taking,  and  how  revolu- 
tionary were  the  prospects  that  it  involved.  But  what  we 
had  seen  had  been  based  upon  a  knowledge  of  anatomy  which 
had  been  acquired  in  a  ten  year's  experience  in  teaching,  and 
upon  such  a  mass  of  confirmatory  experience,  surgical  and 
medical,  as  to  be  overwhelmingly  convincing  if  it  could  only 


OEIFICIAL  SURGERY.  19 

be  massed  and  presented  in  consecutive  form,  especially  if  the 
profession  were  only  fair-minded  enough  to  want  the  truth 
and  recognize  it  when  they  had  the  opportunity.  Hesitation 
prevailed  but  for  a  short  time.  It  was  decided  to  demonstrate 
the  courage  of  our  convictions,  and  the  following  lecture  was 
delivered.  The  original  copy  can  be  found  in  the  Medical 
Era  for  March,  1886. 

A  SURGICAL  TALK  UPON  THE  ORIFICES  OF  THE  BODY. 

The  subject  upon  which  I  shall  speak  today  is  the  one  I 
briefly  referred  to  at  last  Tuesday's  clinic.  It  is  intended  as 
a  resume  of  some  of  the  clinical  work  which  you  have  witnes- 
sed during  the  present  session.  There  is  but  one  thought  in 
this  talk  of  today,  but  as  I  deem  it  of  more  importance  than 
any  other  of  the  present  course,  I  am  anxious  to  present  it 
to  you  plainly  and  concisely,  that  you  may,  in  case  of  neces- 
sity, safely  rely  upon  your  notes  for  future  reference.  It  is 
a  comprehensive,  far-reaching  idea — more  so,  perhaps  than 
you  now  appreciate.  It  is  not  a  hasty  conclusion,  born  on 
the  spur  of  the  occasion,  but  a  thoroughly  tested  theory.  Let 
us  call  it  a  surgical  talk  upon  the  orifices  of  the  human  body. 

In  this  talk  we  shall  have  to  recall  just  a  little  anatomy, 
refer  slightly  to  physiology,  tread  gently  on  the  toes  of  theory 
and  practice,  and  trespass  somewhat  upon  the  chair  of  gyne- 
cology.  We  shall  wander  from  surgery  proper,  however,  as 
little  as  is  consistent  with  a  fair  presentation  of  the  subject 
as  a  purely  surgical  thought. 

The  cerebro-spinal  nervous  system  is  the  grand  con- 
necting link  between  body  and  soul.  It  receives  a  steady 
influx  of  life,  and  by  it  makes  the  entire  organism  dance  to 
whatever  music  it  wishes.  The  rest  of  the  body  is  its  faithful 
servant,  its  slave;  but  even  slaves  get  sick  and  are  at  times 
unfit  for  their  master's  bidding,  and  what  I  shall  say  today 
concerns  the  health  and  prosperity  of  the  body  as  it  is  acted 
upon  by  other  influences  than  those  which  come  through  the 
cerebro-spinal  system. 

When  a  bolus  of  food  descends  below  the  pharynx  it  is 


20  ORIFICIAL  SURGERY. 

carried  to  the  intestinal  tract,  digested,  assimilated,  carried 
by  the  thoracic  duct  into  the  left  subclavian  vein — except 
what  is  taken  up  by  the  mesenteric  veins  themselves — passed 
into  the  heart,  and  circulated  first  through  the  lungs  for  the 
breath  of  life,  and  thence  throughout  the  entire  body  by  a 
nervous  system,  entirely  distinct  from  the  cerebro-spinal,  ex- 
cept as  its  branches  seek  out  the  cerebro-spinal  nerves  for  the 
purpose  of  a  mutual  exchange  of  ideas  in  matters  of  common 
interest.  The  brains  of  this  system,  which  you  at  once  recog- 
nize as  the  sympathetic,  are  small  knots  of  gray  matter,  con- 
nected by  nerve  cords  as  beads  are  held  together  by  strings, 
and  lying  in  two  parallel  rows  in  front  of  the  spinal  column, 
extending  from  the  base  of  the  cranium  to  the  coccyx.  From 
these  knots  of  brain  substance  fine  tendrils  reach  out  and, 
seeking  the  branches  of  the  arterial  tree,  climb  by  their  aid 
to  every  nook  and  corner  of  the  human  anatomy.  This  sympa- 
thetic nerve  is  the  great  nerve  of  animal  existence ;  on  its 
tonicity  and  uninterrupted  action  hangs  our  very  life.  The 
peristaltic  action  of  the  bowels,  of  the  glands,  of  the  blood- 
vessels and  of  the  excretory  organs  is  dependent  upon  its  in- 
fluence ;  when  it  is  strong  and  vigorous  all  the  processes  of 
waste  and  repair  are  carried  on  with  a  vigor  that  laughs  at 
the  excesses  and  irregularities  with  which  the  erratic  cerebro- 
spinal  system  taxes  it,  and  it  keeps  under  subjection  inherited 
and  acquired  tendencies  of  every  description.  Who  ever  heard 
of  consumption  or  scrofula  or  syphilis  consuming  its  prey 
when  plenty  of  wholesome  nourishment  reaches  the  capillaries  ? 
If  colds  and  bruises  and  miasms  overcome  a  body,  it  is  because 
that  body  is  too  enfeebled  to  resist  their  influence. 

Let  us  regard,  then,  this  point  as  established :  that  a 
vigorous  sympathetic  nervous  system  means  health  and  long 
life.  What  surgical  interest  have  we  in  this  fact?  It  can 
be  told  in  just  one  sentence.  The  weakness  and  the  power 
of  the  sympathetic  nerve  lies  at  the  orifices  of  the  body. 
Surgery  must  keep  these  orifices  properly  smoothed  and  di- 
lated. You  will  have  to  chase  that  sympathetic  nerve  from 
one  end  of  the  body  to  the  other,  peering  in  at  every  crack 
and  crevice  where  mucous  membrane  touches  skin,  if  you  wish 


OBIPIC'IAL   SURGERY.  21 

satisfactorily  to  comprehend  the  pathological  basis  for  the 
great  majority  of  disorders  which  take  advantage  of  an  ener- 
vated sympathetic  nerve. 

If  the  anterior  nares  is  fissured,  incise  it  or  cauterize  it. 
Your  patient  will  thank  you  the  next  time  you  see  him.  Operate 
at  an  earlier  stage  upon  labial  irritations  and  tumors  than 
upon  similar  conditions  on  either  mucous  membrane  or  skin 
away  from  the  orifice  of  the  mouth.  If  a  palate  is  chronically 
elongated  and  causing  an  irritating  throat  cough,  do  not  hesi- 
tate to  shorten  it  with  a  pair  of  scissors.  If  tonsils  are  hyper- 
trophied  and  yielding  an  abundant  product  of  mucous  or 
calcareous  matter,  and  thickening  the  voice  and  congesting 
the  fauces  and  pharynx,  use  your  tonsillotome.  When  a  new- 
born boy  presents  a  pin-hole  opening  in  the  foreskin,  what  is 
the  use  of  postponing  an  operation  until  some  slight  irritation, 
as  from  teething  or  cold,  precipitates  him  into  convulsions  ?  Or, 
if  he  escapes  this  calamity  until  approaching  puberty  starts  an 
irritation  which  induces  masturbation,  and  ushers  him  into  an 
era  of  enervating  sensuality  which  will  surround  him  with  a 
moral  and  physical  depression  which,  if  he  ever  escapes,  will 
entail  years  of  trouble  and  suffering,  not  to  mention  the  ground 
which  such  a  condition  lays  for  venereal  vaccination.  Circum- 
cise early  and  often. 

Men  have  no  menstrual  period.  Nocturnal  emissions,  com- 
ing at  any  time  or  in  any  case,  are  unnatural  and  depleting, 
and  the  doctor  who  claims  to  regard  them  as  a  normal  physio- 
logical process,  in  my  humble  estimation,  is  simply  apoligizing 
for  his  inability  to  cure  them.  They  are  always  a  product  of 
an  irritation  which  you  can  and  should  remove.  Urethral  dila- 
tation with  cold  steel  sounds,  practiced  weekly,  will  soon  re- 
store to  its  proper  tone  the  sexual  system.  In  the  few  cases 
which  do  not  promptly  respond  to  this  treatment,  you  will  find 
other  sources  of  irritation  which  you  must  seek  out  and  remove. 

If  you  wish  to  reduce  an  enlarged  prostate,  pass  sounds. 
Their  tonic  action,  by  touching  the  orifices  of  the  prostatic 
ducts,  will  invigorate  and  reduce  to  healthy  condition  the  en- 
tire gland.  If  you  wish  to  benefit  a  chronic  orchitis  or  epididy- 
mitis,  pass  sounds.  They  come  into  contact  with  the  orifices 


22  ORtPIClAL  SURGERY. 

of  the  ejaculatory  ducts,  and  as  soon  as  these  are  relieved  of 
congestion  or  subacute  inflammation,  the  circulation  will  be 
restored  throughout  the  entire  testicle  and  its  vas  deferens. 

The  gynecologist  will  tell  you  that  an  irritable  hymen  may 
induce  vaginismus,  uterine  congestion  and  pruritus  vulva.  I 
will  assure  you,  if  he  does  not,  that  its  baneful  influence  does 
not  stop  here.  Aside  from  the  nervous  irritability  and  sexual 
disorders  from  it,  its  influence  is  sometimes  reflected  to  the 
digestive  tract,  and  how  much  farther  I  will  not  say.  I  have 
cured  two  cases  of  chronic  diarrhea  by  the  simple  practice  of 
removing  an  irritable  hymen.  So,  if  the  os  vaginae  is  rough, 
render  it  smooth. 

The  reputation  of  the  uterus  as  a  centre  of  all  sorts  of 
reflex  disorders  and  affections  which  are  not  felt  at  their  start- 
ing-point, is  too  well  established  to  require  further  considera- 
tion in  this  connection.  Let  me  simply  call  your  attention  to 
one  essential  point  in  an  examination  to  determine  a  uterine 
condition,  when  you  are  searching  for  the  origin  of  reflex 
troubles;  look  at  the  internal  and  at  the  external  os.  Cold 
steel  will  aid  you  here  as  it  does  in  troubles  of  the  male  sexual 
system.  It  will  tone  up  and  strengthen  when  the  uterus  is 
atrophied  and  too  weak  to  support  itself  so  that  it  topples  over 
into  the  various  misplacements;  it  will  restore  capillary  circu- 
lation and  reduce  hypertrophy  when  congestion  and  subacute 
inflammation  have  distorted  its  shape  and  disturbed  its  position. 

But  of  all  openings  of  the  body,  the  one  most  neglected, 
most  abused,  yet  most  influential  in  its  action  upon  the  general 
health  and  tonicity  of  the  human  organism,  is  the  lower  open- 
ing of  the  bowels.  I  refer  to  the  last  inch  of  the  rectum,  from 
the  upper  border  of  the  internal  sphincter  to  the  lower  border 
of  the  external  sphincter.  When  you  stop  to  think  of  the 
anatomical  situation  of  this  part — at  the  very  base  of  the  body 
— and  that  its  return  circulation  passes  into  the  portal  system, 
and  hence  affects  and  is  affected  by  the  condition  of  the  vari- 
ous digestive  organs  in  general,  and  the  liver  in  particular; 
when  you  think  also  how  the  largest  part  of  the  rectum  is  sud- 
denly puckered  down  to  the  narrow  limits  of  this  small  open- 
ing; when  you  think,  too,  of  the  almost  universal  carelessness 


OBIFICIAL  SUBGEBY.  23 

of  mankind  in  attending  regularly  to  the  demands  of  nature, 
that  this  part  shall  be  kept  empty  and  free  from  the  irritation 
of  prolonged  distention;  and  when,  last  of  all,  but  not  least, 
you  recall  the  great  variety  of  harsh  and  scraping  debris,  from 
the  rough  and  clinging  stones  of  small  fruits,  such  as  straw- 
berries, raspberries,  blackberries,  etc.,  to  the  pricking  oatmeal 
husk,  you  will  no  longer  wonder  that  the  lower  rectum  should 
frequently  become  disordered,  but,  rather,  be  surprised  that  the 
care  of  this  part  has  so  long  been  entrusted  to  the  unskilled 
hands  of  incompetent  specialists,  and  that  it  has  escaped  the 
notice  of  regularly  educated  practitioners  of  medicine  and  sur- 
gery. 

Of  course,  when  a  patient  is  so  badly  afflicted  as  to  be  con- 
scious of  local  trouble,  and  comes  to  you  with  his  case  already 
diagnosed,  perhaps  you  would  be  compelled  to  treat  his  piles, 
or  cauterize  his  fissure  or  ulcer,  or  operate  on  his  fistula — 
about  the  only  conditions  that  would  speak  for  themselves 
loudly  enough  to  diagnose  his  own  case  and  compel  him  to 
apply  to  you  for  relief.  But  a  uterus  can  express  its  wail  of 
complaint  by  dyspepsia,  by  headache,  by  heartache,  or  func- 
tional derangements  almost  anywhere  in  the  body.  So  can  a 
hymen,  so  can  a  prostate,  so  can  a  testicle,  so  can  a  glans  penis. 
Why  should  the  part  that  is  more  exposed  to  incidents  and  ac- 
cidents than  all  the  others  put  together,  be  less  potent  to  tele- 
phone its  distress  to  sympathizing  relatives  or  friends  ?  If  you 
think  so  you  are  mistaken,  for  a  rectum  has  a  sphere  of  influ- 
ence in  the  human  economy  as  much  wider  than  the  other 
openings  as  its  usefulness  is  greater. 

The  particular  disorders  to  which  this  part  is  liable,  is 
not  for  us  to  discuss  today.  That  topic  will  receive  attention 
next  Thursday.  Today's  talk  treats  but  of  the  general  outline 
and  background  of  a  picture  whose  individual  figures  will  be 
drawn  hereafter.  I  have  seen  surgical  treatment  of  the  rec- 
tum clear  a  tongue  that  was  chronically  coated,  in  six  hours 
after  the  operation.  I  have  seen  it  cure  rapidly  and  perman- 
ently an  acne  of  the  lips  and  tip  of  the  nose.  I  have  seen  it 
take  pallor  from  the  mouth  and  restore  an  even  color  to  the 
face.  I  have  seen  it  cure  inveterate  catarrh,  relieve  obstinate 


24  ORIFICIlAL  SURGERY. 

constipation,  cure  headache,  spasmodic  urethral  stricture, 
cough,  uterine  congestion,  leucorrhea,  and  other  troubles  too 
numerous  to  mention.  I  know,  and  so  can  anyone  know,  who 
will  investigate  for  himself,  that  rectal  conditions  influence 
waste  and  repair  more  than  any  other  one  point  of  the  system, 
and  that  no  chronic  case  is  thoroughly  examined  without  rectal 
exploration,  and  it  is  my  duty  to  make  you  all  surgeons  to  the 
extent  of  teaching  you  what  to  look  for. 

There  is  no  time  today  for  a  detail  of  cases  in  illustration. 
The  discussion  of  this  subject  has  been  purposely  postponed 
until  the  close  of  the  term,  that  you  might  watch  the  extensive 
surgical  clinic  and  see  for  yourselves.  As  I  stand  here  today, 
your  fixed  attention  and  complimentary  bearing  tell  me  of 
your  hearty  and  intelligent  endorsement  of  every  word  spoken. 
I  thank  you  heartily  for  your  patient  waiting,  as  we  have  cut 
and  trimmed  and  pruned  the  various  orifices  of  the  body  in 
your  presence.  The  results  of  this  work  you  have  witnessed 
from  time  to  time.  Nothing  has  been  concealed  or  kept  back 
from  you.  We  have  studied  together,  and  let  this  summary  put 
a  meaning  to  the  work — let  it  give  a  "method  to  the  madness" 
that  otherwise  might  seem  eccentric. 

In  conclusion,  let  me  sum  up  the  entire  subject  in  a  single 
sentence.  Bring  me  an  individual  with  clean  lips  and  nostrils ; 
a  palate  of  proper  length  and  unobtruding  tonsils;  a  rectum 
that  presents  neither  piles,  prolapsus,  fissure,  ulcer,  pockets 
nor  papillae — an  individual  whose  sexual  orifices  are  smooth 
and  free  from  all  irritation;  if  it  be  a  man,  his  foreskin  shall 
be  free,  the  frenum  of  sufficient  length,  the  urethral  passage 
smooth  and  normal  in  size,  especially  in  its  prostatic  portion ; 
if  a  woman,  her  hymen  must  be  pale  and  atrophied,  her  urethra 
devoid  of  caruncles  and  ulcerations,  her  internal  and  external 
os  uteri  reasonably  patulous,  and  without  undue  sensitiveness ; 
bring  such  an  individual,  and  I  will  point  to  the  same  person 
and  show  you  a  human  being  whose  digestion  is  good,  whose 
sleep  is  sweet  and  restful,  whose  capillary  circulation  is  superb, 
whose  very  existence  is  a  constant  source  of  uninterrupted  de- 
lights. Such  men  and  women  maintain  a  steady  poise  of  mind 
and  body — they  live  to  the  fullness  of  time,  and,  unless  removed 


ORIFICIAL  SURGERY.  25 

by  accident,  their  dissolution  takes  place  on  the  principle  of  the 
"one-boss  shay" — they  settle  slowly  and  peacefully  into  their 
last  sleep,  just  because  their  life's  time-piece  has  run  down. 

On  the  other  hand,  introduce  to  me  a  mortal  suffering  with 
passive  congestion  in  various  parts,  whose  blood  finds  its  lazy 
way  back  to  the  heart  by  slow  stages  because  the  peristalic 
action  of  the  arteries  is  tired  out — a  person  whose  vitality  is 
low,  and  whose  poor,  enfeebled  body  begins  to  be  the  prey  of 
inherited  or  acquired  tendencies — consumption,  scrofula,  syph- 
ilis, organic  derangements,  or  whatever  form  they  may  take — 
show  me  such  an  individual,  and  they  are  as  numerous  as  with- 
ered leaves  in  autumn,  and  I  will  stake  the  reputation  of  this 
idea  that  I  shall  be  able,  without  straining  a  point,  to  find  legi- 
timate fault  with  the  condition  of  some  one  or  more  of  the 
various  orifices  of  the  body. 

This  lecture  was  delivered  with  such  intensity  of  expres- 
sion, with  such  earnestness  and  force,  that  it  produced  a  most 
remarkable  effect  upon  the  class.  The  applause  following  the 
lecture  was  deafening  and  lingering  and  followed  by  hand- 
Shaking,  which,  of  course,  might  result  from  any  lecture  de- 
livered with  a  sufficient  degree  of  warmth.  But  the  most  re- 
markable effect  of  the  lecture  was  in  the  fact  that  in  the  fol- 
lowing three  weeks  which  remained  before  the  term  closed, 
notwithstanding  the  fatigue  of  the  class  and  their  nearness  to 
examinations,  sixteen  members  of  the  class  itself  presented 
themselves  for  examination  and  operation  upon  the  new  prin- 
ciple. Some  were  troubled  with  chronic  headaches,  some  with 
dyspepsia,  some  with  constipation,  some  with  insomnia,  some 
with  lack  of  memory,  and  others  with  other  troubles  which 
have  long  since  been  forgotton  except  by  those  who  possessed 
them.  These  sixteen  were  all  operated  upon,  and  the  thought 
was  thus  put  to  an  immediate  test  by  those  who  had  observed 
its  workings  in  the  clinic  during  the  entire  term.  The  results 
of  this  crucial  test  were  so  brilliant  and  satisfactory  that  from 
that  time  its  popularity  with  the  class  became  thoroughly  es- 
tablished and  has  never  since  flagged.  As  the  years  go  by, 
every  class  which  has  graduated  from  the  college  has  mani- 
fested its  profound  interest,  respect  and  firm  belief  in  the  teach- 


26  ORIFICIAL  SURGERY. 

ing  of  the  philosophy.  They  have  seen  its  successes  and  fail- 
ures from  year  to  year,  have  heard  it  expounded  and  heard  it 
criticized,  have  been  in  a  perfectly  impartial  attitude  in  every 
particular,  but  their  yearly  indorsement  and  adoption  of  the 
teachings  of  the  orificial  department  has  been  a  great  source 
of  encouragement  and  cheer  to  the  founder  of  the  philosophy. 
Many  of  the  class  experiences  with  the  work  have  been  com- 
paratively uneventful,  but  the  class  of  '85- '86  witnessed  the 
gestation  and  birth  of  the  thought  and  listened  to  its  first  full 
expression  in  the  lecture  which  is  here  published,  and  it  offered 
so  many  of  its  numbers  as  examples  for  the  demonstration  of 
the  new  thought  that  it  will  forever  rank  as  a  class  of  remark- 
able courage  and  fidelity  to  its  convictions  of  what  it  was  satis- 
fied was  a  great  truth,  and  its  various  members  by  their  actions 
became  pioneers  in  its  acceptation  so  far  as  the  medical  pro- 
fession is  concerned. 


CHAPTER  II. 

A  BRIEF  CHAPTER  IX  THE  HISTORY  OF  ORIFICIAL 
SURGERY. 


K,    H.   PRATT,   M.    D. 


The  orificial  thought,  as  it  now  exists,  was  born  a  part  at 
a  time,  like  any  other  baby,  and  was  not  delivered  into  the 
hands  of  the  medical  profession,  for  its  adoption  or  rejection, 
until  February,  1886,  although  portions  of  the  thought  had 
found  expression  at  earlier  dates. 

The  order  in  which  the  various  pelvic  organs  established 
themselves,  in  an  appreciation  which  gradually  extended  until 
they  were  all  included  in  what  is  known  as  orificial  considera- 
tion, was  as  follows :  First,  laceration  of  the  cervix  uteri ;  later 
on  periodical  uterine  dilatation  with  graded  sounds. 

Soon  afterward  the  male  foreskin  aroused  reflection,  and 
the  male  urethra,  meatus  and  frenum  soon  followed.  Then 
came  the  hymen,  after  which  soon  followed  the  clitoris  and  its 
hood  and  the  female  urethra,  and,  later  on,  rectal  conditions. 


ORIFICIAL  SURGERY.  27 

It  was  a  summing  up  of  years  of  experience  with  these 
various  parts  and  the  influence  they  had  been  found  to  ex- 
ercise over  the  bodily  economy  that  suddenly  took  place  in  a 
most  unexpected  manner  at  the  surgical  clinic  in  the  Chicago 
Homeopathic  College  on  a  Tuesday  morning  in  the  early  part 
of  February,  1886,  when  the  startling  announcement  was  made 
by  the  author  that  at  the  next  surgical  hour  students  would  be 
invited  to  listen  to  a  lecture  upon  a  surgical  cure  for  chronic 
diseases. 

The  effect  of  the  lecture  was  so  profound  that,  although  it 
was  within  three  weeks  of  the  close  of  the  winter  term  and  the 
students  were  busy  preparing  for  examination,  the  principles 
enunciated  were  so  clearly  understood  by  the  students  and  so 
practically  indorsed,  that  during  that  three  weeks  sixteen  of 
its  members  applied  for  orificial  treatment  and  received  it. 
One  was  troubled  with  headaches,  one  with  insomnia,  two  or 
three  suffered  from  dyspepsia,  several  had  seminal  losses,  and 
the  whole  sixteen  were  one  by  one  placed  under  an  anesthetic 
and  given  the  benefit  of  orificial  work,  and  without  exception, 
there  was  ample  excuse  for  the  treatment.  Reports  of  the  stu- 
dents upon  the  effects  of  the  work  in  their  individual  cases 
were  of  the  most  flattering  and  satisfactory  nature,  so  much 
so  that,  in  order  to  put  the  new  idea  to  the  greatest  possible 
test,  the  author's  weekly  surgical  clinic  of  the  college  was  run 
upon  orificial  principles  during  the  entire  year,  winter  and 
summer,  without  interruption,  and  the  amphitheater  of  the 
institution  bcame  a  weekly  debating  room,  where  objections 
were  raised  and  answered,  where  the  orificial  thought  was  re- 
peatedly put  to  the  severest  possible  tests  as  to  its  reliability 
and  efficiency,  and  where  doubts  and  skepticisms  were  as  wel- 
come as  commendations  and  indorsements. 

One  of  the  first  effects  of  pelvic  work  accomplished  under 
the  effects  of  an  anesthetic  noticed,  was  the  immediate  influence 
of  rectal  dilatation  upon  the  respiration  in  cases  where  the  sym- 
pathetic nerve  was  in  a  normal  condition.  At  that  time  rectal 
surgery  was  more  or  less  in  disrepute  among  doctors  generally. 
People  were  so  sensitive  about  rectal  examinations,  and  doctors 
were  so  shy  about  making  them,  that  only  in  severe  cases  of 


28  ORIFICIAL  SURGERY. 

self-conscious  rectal  troubles  were  examinations  of  this  part 
deemed  necessary  either  by  patient  or  physician,  as  both  were 
apparently  anxious  to  avoid  the  subject  as  much  as  possible, 
and  only  in  extreme  cases  was  this  diffidence  overcome  and  a 
local  inspection  made.  Rectal  diseases  were,  as  a  general  rule, 
in  the  hands  of  itinerants  who  were  looked  down  upon  as  medi- 
cal scavengers,  and  reputable  medical  men  were  in  the  habit 
of  ignoring,  as  far  as  possible,  even  the  existence  of  the  rec- 
tum itself.  There  were  no  satisfactory  rectal  instruments  in 
the  shops,  and  a  good,  practical  rectal  speculum  was  unobtain- 
able either  in  the  United  States  or  on  the  Continent,  to  say 
nothing  of  other  instruments  necessary  for  the  practice  of 
rectal  surgery  or  other  rectal  treatments.  The  dilatation  which 
at  this  time  was  practiced  was  universally  accomplished  with- 
out instruments. 

A  few  incidents  which  occurred  in  the  first  series  of  ori- 
ficial  clinics  will  serve  to  illustrate  the  nature  of  what  was 
constantly  recurring.  The  professor  of  anatomy  of  the  college 
was  a  personal  friend  of  the  author,  but  skeptical  as  to  the 
utility  of  orificial  work,  and  upon  one  occasion,  soon  after  the 
close  of  the  term,  visited  the  clinic  just  to  see  what  was  going 
on,  being  attracted  by  the  stir  which  the  operations  upon  the 
students  had  made  in  the  college.  An  anesthetized  patient  lay 
upon  the  operating  table  when  the  professor  entered,  and  the 
question  of  the  effect  of  rectal  dilitation  upon  the  respiration 
was  under  discussion.  The  clinician  had  just  called  the  atten- 
tion of  the  visiting  doctors  and  students  in  attendance  to  the 
existence  of  two  nervous  systems  of  the  body,  the  cerebro- 
spinal  and  the  sympathetic,  the  one  registering  conscious  sen- 
sations and  acts  of  conscious  volition,  the  other  performing  the 
involuntary  and  unconscious  service  of  bodily  function  and 
nutrition.  Attention  was  called  to  the  fact  that  the  cerebro- 
spinal  system  was  sometimes  abnormally  sensitive  or  hyperes 
thetic,  and  sometimes  abnormally  insensitive  or  anesthetic,  and 
the  statement  was  made  that  the  sympathetic  nervous  system 
enjoyed  the  same  privileges,  that  is,  it  sometimes  would  be  ab- 
normally sensitive  and  be  immediately  startled  into  undue 
activity  on  the  slightest  irritation  of  any  of  the  mucous  sur- 


OKIFICIAL  SURGERY.  29 

faces  which  it  supplied,  and  at  other  times  it  would  be  so  dor- 
mant or  anesthetic  as  to  refuse  to  respond  even  to  severe  forms 
of  irritation.  Where  the  sympathtic  nerve,  however,  was  in 
normal  condition,  it  was  held  that  rectal  dilatation  would  in- 
duce such  spasmodic  action  of  the  diaphragm  or  glottis  or  both, 
while  it  was  being  practiced,  as  to  more  or  less  completely  sus- 
pend respiration,  after  which  a  deep  inspiration  would  follow, 
this  in  turn  to  be  succeeded  by  universal  flushing  of  the  capil- 
laries throughout  the  entire  body,  for  the  heart's  action,  al- 
though somewhat  inhibited  by  the  dilatation,  would  be  more 
than  counterbalanced  by  the  temporary  paralysis  of  the  vaso- 
motor  system  of  the  nerves,  thus  opening  arteries  and  favoring 
a  more  thorough  rushing  of  the  blood  to  the  tissues  universally. 
In  this  way,  it  was  explained  that  cold  extremities  were  almost 
immediately  warmed,  local  congestions  and  inflammations  were 
immediately  relieved,  and  the  capillary  circulation  throughout 
the  system  equalized.  As  all  organic  activity,  including  growth 
and  repair,  is  accomplished  by  the  blood  stream,  the  effect  of 
rectal  dilatation  upon  chronic  diseases  generally  was  thus  ex- 
plained. In  order  to  impress  the  visiting  professor  with  the 
first  point  of  the  chain  of  argument,  viz. :  that  rectal  dilatation, 
where  the  sympathetic  nerve  was  in  a  normal  condition,  would 
for  the  time  being  suspend  the  respiration,  the  sleeping  patient 
was  placed  upon  the  side,  and  the  professor  himself  invited  to 
practice  the  dilatation,  while  the  company  was  requested  to 
maintain  silence  in  order  to  note  the  effect  of  his  manipula- 
tions. Inserting  his  thumbs  back  to  back  in  the  anus,  he  care- 
fully and  thoroughly  performed  the  act  of  dilatation  without 
producing  the  slightest  disturbance  of  the  respiration  of  the 
patient.  As  he  turned  away  a  smile  of  apparent  satisfaction  at 
the  failure  of  the  experiment  spread  over  his  countenance. 
When  he  was  accused  of  merriment,  he  frankly  confessed  to 
being  amused  at  the  incident.  As  the  clinician,  however,  was 
not  satisfied  with  the  test,  the  professor  was  requested  to  sus- 
pend his  judgment  for  a  moment  and  witness  a  repetition  of 
the  experiment.  The  operator  then  inserted  the  middle  and 
index  fingers  of  his  two  hands,  back  to  back,  completely  within 
the  anus  so  as  the  secure  a  substantial  grip  upon  the  internal 


30  OEIFICIAL  SUKGERY. 

sphincter.  Upon  then  practicing  thorough  dilatation,  the  ex- 
pected phenomenon  of  suspended  respiration  was  conspicuous- 
ly produced,  much  to  the  amazement  of  the  witnessing  profes- 
sor and  the  audience,  not  to  mention  the  satisfaction  of  the  sur- 
geon, who  then  remarked  that  smiles  were  now  in  order,  and 
that  the  professor  also  deserved  the  thanks  of  the  audience  for 
aiding  in  the  demonstration  upon  a  living  subject  of  a  bit  of 
important  anatomy  and  physiology.  With  his  thumbs  the  pro- 
fessor had  seized  merely  the  external  sphincter  which  is  sup- 
plied by  the  cerebro-spinal  nervous  system,  and  although  he 
practiced  dilatation  of  this  muscle  honestly,  it  produced  no  ap- 
parent effect  upon  the  respiration  or  circulation.  The  surgeon, 
however,  by  securing  with  his  fingers  a  higher  impingement  of 
the  anus  and  practicing  dilatation  upon  the  internal  sphincter, 
was  able  to  suspend  the  respiration,  because  the  internal  sphinc- 
ter is  a  muscle  of  the  involuntary  type  and  supplied  by  the 
sympathetic  nerve,  thus  establishing  two  important  facts,  one 
that  the  function  of  respiration  is  dominated  by  the  sympa- 
thetic nerve,  at  least  during  anesthesia,  and  that  in  conse- 
quence of  this,  forms  of  rectal  irritation  which  induce  spas- 
modic contraction  of  the  internal  sphincter  are  more  disas- 
trous from  the  standpoint  of  bodily  waste  and  repair 
than  those  which,  although  they  may  cause  more  pain 
and  self-consciousness  on  the  part  of  the  patient,  appeal 
merely  to  muscles  and  surfaces  supplied  by  the  cerebro-spinal 
system.  The  professor  fully  appreciated  the  object  lesson,  and 
later  on  in  his  private  practice  took  advantage  of  the  sug- 
gestion. 

Not  long  after  this,  however,  another  member  of  the  facul- 
ty, by  no  means  so  kindly  disposed,  presented  himself  at  the 
clinic  for  the  purpose  of  entering  protest  against  the  promin- 
ence which  was  being  given  to  the  orificial  thought.  When  he 
entered  the  clinic  room  a  patient  was  on  the  operating  table, 
for  the  purpose  of  removing  the  lower  jaw  for  necrosis  of  that 
bone.  Before  the  operation  was  begun  the  attention  of  those  in 
attendance  was  attracted  to  the  effect  of  rectal  dilatation  over 
respiration,  as  on  the  occasion,  just  mentioned.  No  sooner  had 
the  statement  been  made  that  rectal  dilatation  for  the  time 


OEIFICIAL  SURGERY.  31 

being,  would  suspend  respiration,  and  by  its  secondary  action 
deepen  it,  thus  producing  a  universal  flushing  of  the  capillaries, 
than  the  self-constituted  disturber  of  the  peace  immediately 
disclosed  the  hostility  of  his  attitude  by  scoffing  at  the  state- 
ment and  asserting  that  a  like  effect  could  be  produced  by 
pinching  the  skin  of  the  patient  or  by  hurting  her  anywhere. 
The  author  immediately  accepted  the  challenge  and  ordered 
the  patient  to  be  put  in  a  position  for  rectal  dilatation.  The 
case  happened  to  be  one  unusually  susceptible  to  rectal  dila- 
tation, and  could  easily  have  been  choked  to  death  had  the  dila- 
tation been  sufficiently  prolonged.  As  soon,  however,  as  the 
blood  had  become  well  blackened  by  the  lack  of  oxygen,  the 
dilatation  was  stopped  and  air  was  ushered  into  the  lungs  with 
a  deep,  gasping  inspiration  which  soon  restored  the  complexion 
of  the  sleeping  patient  to  a  bright,  red,  wholesome  color.  To 
exclude  accident,  the  process  was  repeated,  but  with  the  same 
result.  The  patient  was  then  placed  at  the  disposal  of  the  pro- 
fessor who  came  to  protest  against  the  idea,  and  his  first  im- 
pulse was  to  forcibly  flex  the  toes,  but  after  partly  removing 
one  of  her  'shoes,  he  changed  his  mind  and  seized  her  in  the 
right  groin  by  a  powerful  clutch  of  both  hands,  but  the  ex- 
ercise of  all  the  force  at  his  command  was  unavailing.  The 
patient  being  thoroughly  anesthetized,  no  amount  of  injury  to 
the  parts  supplied  by  the  cerebro-spinal  nervous  system,  or 
even  to  those  supplied  by  the  sympathetic  nerve,  except  the 
pelvic  outlets,  could  be  so  cut  or  squeezed  or  injured  in  any 
way  as  in  the  slightest  degree  to  influence  the  rhythm  of  re- 
spiration, for  there  is  no  clinic  in  the  world  upon  which  the 
effect  upon  the  respiration  as  described  is  ever  produced,  ex- 
cept a  clinic  involving  the  impingement  of  terminal  nerve  fib- 
ers of  the  pelvic  organs.  The  professor  was  reminded  that  per- 
haps she  was  asleep  or  had  gone  on  a  journey,  and  was  urged 
to  pinch  her  harder,  much  to  his  own  irritation  and  the  amuse- 
ment of  those  who  were  witnessing  the  experiment.  The  pur- 
pose of  the  professor  in  visiting  the  clinic  was  too  deeply 
malicious,  however,  to  be  thus  easily  balked.  He  then  gave 
vent  to  his  opinion  in  most  emphatic  terms,  that  the  whole  pro- 
ceeding was  most  thoroughly  unscientific ;  that  to  account  for 


32  ORIPICIAL  SURGERY. 

J 

chronic  diseases  by  universal  existence  of  pelvic  irritation  was 
simply  ridiculous,  and  that  to  attempt  their  cure  by  any  type 
of  pelvic  attention,  thus  placing  orificial  work  in  the  light  of  a 
panacea  for  human  ills,  was  misleading  and  detrimental  to  the 
best  interests  of  the  college,  the  profession  and  the  community, 
and  he  had  come  to  call  a  halt  upon  all  such  teaching.  The 
professor  was  thanked  for  his  honest,  fearless  and  frank  ex- 
pression of  opinion  and  was  asked  to  employ  his  "scientific" 
knowledge  for  a  better  interpretation  of  a  large  number  of 
clinical  facts  which  were  then  presented  to  him  for  consider- 
ation. Case  after  case  was  then  brought  in  which  had  been 
cured  by  orificial  methods.  One,  a  chronic  abscess  of  the  groin 
in  a  girl  ten  years  of  age,  cured  in  three  days'  time  by  loosen- 
ing the  hood  of  the  clitoris  and  removing  a  few  pockets  and 
papillae  from  the  rectum.  A  man  with  syphilitic  enlargement 
of  the  glands  of  the  neck,  axilla  and  groins,  accompanied  by 
extreme  emaciation,  suffering  for  six  months  and  defying  all 
other  forms  of  treatment,  had  been  restored  to  a  normal  con- 
dition of  the  glands  and  to  an  increase  of  twenty  pounds  in 
weight  by  the  removal  of  some  small  hemorrhoids  and  by  cir- 
cumcision. This  was  accomplished  in  three  weeks'  time.  A 
tumor  of  the  breast,  which  otherwise  would  have  required  ex- 
cision, was  completely  absorbed  in  a  few  weeks'  time  after 
much  needed  pelvic  work,  and  so  on. 

Indeed,  for  three  consecutive  hours  a  procession  of  cases 
of  various  kinds  that  had  been  cured  by  orificial  methods  was 
presented  before  the  professor  for  his  consideration,  and  he 
was  asked  to  explain  upon  an  anatomical  and  physiological 
basis  the  extended  application  of  the  work  and  its  phenomenal 
effects  upon  general  nutrition.  The  complete  discomfiture  of 
the  disturbing  member  of  the  faculty  was  accomplished,  and 
his  apology  both  for  his  ignorance  and  for  his  audacity  was 
later  on  secured. 

Throughout  the  year  there  was,  perhaps,  no  more  marked 
exhibition  of  the  power  of  the  work  than  occurred  in  a  case  of 
secondary  syphilis,  which  presented  itself  at  the  clinic  for  re- 
lief one  summer's  day.  He  gave  a  perfect  syphilitic  history, 
so  far  as  the  primary  sore  and  the  subsequent  symptoms  were 


OEIFICIAL  SURGERY.  33 

concerned,  and  when  he  came  before  the  class  was  a  pitiful 
sight  to  behold.  Sores  varying  from  the  size  of  a  small  pea  to 
a  silver  dollar  completely  bespattered  his  skin  surface.  He 
was  stripped  and  photographed.  The  largest  sores  were  upon 
his  body,  but  his  face  and  head  were  thoroughly  sprinkled  with 
them,  as  were  also  the  palms  of  his  hands  and  the  soles  of  his 
feet.  He  had  applied  to  neighboring  clinics  without  relief,  and 
was  so  offensive  in  his  appearance  as  be  an  unwelcome  guest 
wherever  he  went.  No  examination  of  his  pelvic  condition  was 
made  at  the  time  the  case  was  under  inspection,  as  the  influ- 
ence of  orificial  work  upon  the  nutrition  had  long  since  been 
demonstrated  to  be  reliable  regardless  of  whatever  type  of 
pelvic  pathology  might  be  encountered.  His  consent  to  oper- 
ative procedure  was  obtained,  and  after  being  placed  under  an 
anesthetic,  he  was  circumcised,  his  urethra  dilated  with  steel 
sounds  up  to  No.  18,  English  scale,  and  the  rectum  trimmed 
and  dilated.  The  rectum,  although  tightly  contracted,  pre- 
sented no  graver  pathology  than  two  small  rectal  pockets  and 
one  or  two  diminutive  papillae,  the  membrane  covering  the  en- 
tire last  inch  being  atrophied.  The  local  pathology  encountered 
was  so  diminutive  as  to  make  it  seem  unreasonable  to  hope  for 
the  cure  of  the  case  by  its  correction.  Nevertheless,  the  thought 
was  put  to  an  honest  test,  the  work  was  done,  and  strict  instruc- 
tions given  that  the  man  should  receive  no  medicine  whatever 
and  should  not  be  permitted  even  to  take  a  bath.  "When 
brought  before  the  class  at  the  next  clinic  the  change  wrought 
in  his  appearance  was  pronounced.  While  many  of  the  larger 
sores  remained  in  statu  quo,  a  number  of  these  and  multitudes 
of  the  smaller  ones  had  entirely  healed  and  the  scabs  from  them 
had  dropped  off,  disclosing  the  characteristic  color  of  syphilitic 
cicatrization.  At  the  second  clinic  he  was  once  more  stripped, 
and  not  a  sore  remained  unhealed.  He  was  kept  at  the  hospital 
for  one  more  week  for  observation,  but  no  more  sores  appear- 
ing, and  the  man  having  regained  to  a  considerable  extent  his 
vigor  and  comeliness  of  appearance,  was  discharged  as  con- 
valescent. 

It  may  be  well  right  here  to  briefly  describe  some  of  the 
remarkable  cases,  the  study  and  explanation  of  which  ultimate- 


34  OBIFICIAL  SURGERY. 

ly  led  to  the  establishment  of  the  orificial  philosophy.  They 
will  be  presented  in  the  order  in  which  they  occurred,  so  as  to 
accurately  illustrate  the  mental  process  by  which  an  orificial 
explanation  was  arrived  at  as  the  only  scientific  and  rational 
theory  by  which  their  cure  could  be  accounted  for. 

Case  1.  Was  simply  a  nervous,  dyspeptic,  hysterical 
woman,  who,  as  a  result  of  childbirth,  presented  locally  what 
would  now  be  described  as  a  lacerated  hyperplastic  and  eroded 
cervix.  Although  Dr.  Emmet,  of  New  York,  had  but  a  short 
time  previously  recognized  the  importance  of  cervical  repairs 
and  had  dwelt  upon  the  removal  of  cicatricial  plugs  from 
women  who  had  been  torn  in  childbirth,  and  who  had  become 
neurotics,  this  case  was  not  at  the  time  recognized  by  the  auth- 
or as  a  case  for  Emmet's  operation,  and  was  subjected  merely 
to  internal  medication  and  local  treatments  by  means  of  medi- 
cated tampons.  As  the  treatments  were  a  failure,  the  case  fell 
into  the  hands  of  another  doctor,  who  placed  her  under  an 
anesthetic  and  performed  some  kind  of  surgical  operation. 
Years  afterward  the  author  ascertained  that  his  successor  in 
the  case  had  amputated  the  cervix,  but  at  the  time  he  was  led 
to  suppose  that  the  case  was  cured  by  Emmet 's  operation. 

One  lesson  of  this  kind  was  enough  for  the  author,  and 
soon  afterward  followed — 

Case  2.  This  was  a  case  of  what  was  known  at  that  time 
as  galloping  consumption.  The  tubercular  bacillus  had  not 
yet  been  discovered,  so  an  examination  of  the  sputum  was  not 
made,  but  she  had  the  rapidly  increasing  emaciation,  the  night 
sweats  and  hectic  fever,  the  quick  pulse  and  profuse  expector- 
ation ;  also  the  chest  rales  and  percussion  sounds  characteristic 
of  broken-down  lung  tissue.  In  addition  to  this  she  was  suffer- 
ing with  chronic  diarrhea  and  extreme  prostration.  Her  con- 
dition supervened  upon  a  miscarriage  three  months  previous, 
followed  by  what  was  supposed  at  the  time  to  be  a  severe  cold. 
Local  examination  disclosed  a  uterine  condition  similar  to  that 
just  described  in  Case  1.  She  was  a  small,  delicate  woman, 
weighing  not  over  eighty-five  pounds,  and  although  fears  were 
entertained  as  to  the  safety  of  employing  an  anesthetic,  the 
case  was  so  desperate  that  it  seemed  necessary  that  what  re- 


OBIFICIAL  SUEGEEY.  35 

lief  was  attempted  should  be  undertaken  at  once  in  order  to 
have  even  the  slightest  ground  to  hope  for  a  favorable  issue. 
She  was  placed  under  an  anesthetic.  Sim's  speculum  at  that 
time  had  not  been  invented,  neither  had  the  plug  forceps,  nor 
was  the  use  of  guy  ropes  known.  Through  the  blades  of  a  bi- 
valve speculum,  by  the  aid  of  a  pair  of  tenacula,  sharp  pointed 
scissors  and  a  needle  threaded  with  silver  wire,  the  two  cica- 
tricial  plugs  were  removed,  one  from  either  side,  the  lower 
united  portions  of  the  cervix  were  denuded  and  the  parts  were 
brought  together.  Xo  dilatation  of  the  uterus  or  curettement 
was  made  use  of,  and  the  perineum,  although  lacerated,  was 
not  interfered  with.  Neither  the  clitoris  nor  rectum  was 
touched  nor  thought  of.  The  immediate  effect  upon  the  pa- 
tient was  as  startling  as  it  was  alarming.  In  the  afternoon  of 
the  day  of  the  operation  she  was  taken  with  a  chill,  her  pulse 
ran  up  to  1-40  beats  per  minute  and  her  temperatue  reached 
104  degrees  Fahrenheit.  Her  cough  became  dry,  slightly 
streaked  with  blood,  and  expectoration  ceased.  Her  chest  was 
immediately  encased  in  a  flaxseed  jacked,  which  was  changed 
three  times  every  twenty-four  hours.  Internal  medication 
was  employed,  and  the  case  at  the  end  of  three  days  enjoyed 
a  complete  convalescence.  The  cough  entirely  disappeared, 
fever,  night  sweats  and  diarrhea  were  gone,  and  the  recovery 
from  that  time  on  was  uneventful. 

As  a  result  of  the  experience  with  this  case,  lacerations  of 
the  cervix  in  the  practice  of  the  author  were  not  overlooked, 
especially  when  the  healing  had  been  but  partial  and  erosions 
and  hyperplasia  were  encountered. 

In  the  course  of  a  few  months  the  third  case  came  under 
observation. 

Case  3.  Was  a  case  of  paralysis,  thirty-two  years  of  age, 
but  completely  bedridden,  being  unable  to  move  either  of  her 
lower  limbs  and  having  but  slight  use  of  her  arms.  She  was 
unable  to  feed  herself  and  could  not  even  pick  up  a  pin.  As 
she  presented  no  record  of  pelvic  troubles,  her  local  condition 
was  not  even  examined,  and  for  three  months  her  treatment 
consisted  in  the  administration  of  internal  remedies  and  the 
employment  of  a  Faradic  battery.  As  there  was  not  even  the 


36  ORIFICIAL  SURGERY. 

slightest  improvement  after  three  months'  faithful  attention, 
a  local  examination  was  requested  and  obtained.  The  uterus 
was  found  to  be  atrophied  and  presented  what  seemed  like  a 
very  slight  laceration  upon  either  side.  This  had  resulted  from 
a  miscarriage  a  few  years  previous,  as  she  had  never  given 
birth  to  a  child  at  full  term.  Under  an  anesthetic,  the  small 
cicatrical  plugs  were  removed  and  the  wounds  closed  by  silver 
sutures.  To  prevent  the  ends  of  the  twisted  wires  from  prick- 
ing the  vagina  they  were  cut  long  and  curled.  Two  stitches 
were  taken  on  either  side.  The  remarkable  part  of  this  case 
was  that  before  these  stitches  were  removed  from  the  uterus, 
which  was  nine  days  after  the  operation,  the  patient  could 
move  her  toes,  and  her  paralysis  gradually  but  steadily  disap- 
peared until  her  convalescence  was  complete,  and  she  is  at  the 
present  writing  a  strong,  healthy  woman,  fifty-two  years  of 
age,  having  never  since  the  operation  suffered  any  severe 
illness. 

These  cases  furnished  food  for  thought  upon  married 
women  who  had  borne  children  or  sustained  miscarriages,  but 
threw  no  light  upon  female  neurasthenics  who  had  never  con- 
ceived. The  influence  of  the  uterus  in  chronic  ailments  of 
women,  however,  such  as  malnutrition,  chlorosis,  lung  and 
spinal  cord  troubles  began  to  be  appreciated  by  the  author, 
who  felt  the  need  of  some  form  of  uterine  stimulant  that  could 
be  made  use  of  in  cases  not  subjects  for  the  operation  for  lacer- 
ation of  the  cervix.  Spooner's  uterine  tips  were  placed  on  the 
market,  and  uterine  stenosis,  cervical  or  corporeal  endometri- 
tis  and  anteflexion  were  soon  found  to  be  greatly  benefited  by 
their  use,  and  the  correction  of  these  local  troubles  was  in- 
variably beneficial  to  the  general  health  of  most  of  those  who 
were  subjected  to  the  employment.  This  treatment  was  also 
tried  upon  a  few  cases  of  laceration  of  the  cervix  in  hopes 
of  avoiding  that  operation  by  practice  of  uterine  dilatation, 
but  instead  of  being  beneficial,  it  was  found  to  be  harmful,  so 
that  the  practice  of  operating  for  laceration  of  the  cervix  was 
again  resumed,  and  that  of  dilating  lacerated  uteri  was  aban- 
doned. 


ORIFICIAL  SUKGERY.  37 

Case  4.  Was  a  married  woman  having  chronic  diarrhoea 
of  five  years'  standing,  which  had  resisted  the  efforts  of 
several  celebrated  prescribers  and  which  the  author  was  equ- 
ally unsuccessful  in  relieving  by  the  employment  of  internal 
remedies.  The  patient,  aside  from  the  diarrhea,  seemed  to 
enjoy  perfect  health.  Close  questioning  finally  disclosed  the 
fact  that  the  diarrhea  was  always  worse  after  sexual  inter- 
course. This  fact  led  to  a  local  examination,  when  nothing 
abnormal  could  be  observed  except  that  the  base  of  the  hy- 
men was  excoriated.  As  the  hope  of  being  able  to  relieve 
the  case  by  the  exhibition  of  drugs  had  grown  faint  indeed, 
she  was  placed  under  an  anesthetic  and  the  hymen  carefully 
trimmed  away,  with  the  satisfactory  result  of  immediately 
and  permanently  curing  the  diarrhea. 

Case  5.  Was  an  exact  repetition  of  Case  4. 

Case  6.  Was  a  male  child,  nine  months  of  age,  suffering 
from  marasmus,  dyspepsia  and  insomnia.  It  was  a  bottle- 
baby,  but  no  food  could  be  found  that  the  child  ivould  retain 
on  its  stomach.  It  had  never  slept  well  and  was  so  emaciated 
that  at  nine  months  of  age  it  was  one  pound  lighter  than  it 
was  when  three  months  old.  Three  months'  prescribing,  al- 
though the  child's  vomiting  was  stopped,  failed  to  help  it 
to  an  appetite  or  a  good  night's  rest,  and  the  puny,  fretful 
little  boy  was  sent  to  its  grandmother  in  Des  Moines,  Iowa, 
for  a  change  of  climate.  Several  months'  absence  failed  to 
afford  any  relief,  and  as  soon  as  it  returned  home  the  author 
was  again  asked  to  resume  his  care  of  the  child.  No  teeth 
had  as  yet  appeared  and  its  condition  was  so  unpromising  that 
counsel  was  summoned.  As  the  gums  over  the  incisors  were 
somewhat  hardened,  the  consulting  physician  advised  cutting 
them,  as  the  only  treatment  which  he  had  to  suggest  in  the 
case.  No  relief  followed,  and  shortly  the  baby's  lower  limbs 
began  to  swell.  In  desperation,  the  author  had  the  child 
stripped  and  put  through  a  careful  examination  from  head 
to  foot.  No  physical  defects  were  observed,  except  that  the 
opening  of  the  foreskin  was  very  small.  The  author  ex- 
plained to  the  parents  that  it  was  important  to  loosen  and 
retract  the  foreskin  on  general  principles,  as  in  case  the 


38  OKIFICIAL  SURGERY. 

child  lived  to  boyhood  it  would  probably  help  him  to  escape 
from  masturbation  and  its  evil  effects,  no  expectation  being 
entertained,  however,  of  securing  any  immediate  relief  for 
the  child's  dropsical  condition,  malnutrition  and  fretfulness. 
As  there  seemed  nothing  else  to  do  in  the  case,  however,  with 
the  consent  of  the  parents,  by  means  of  a  grooved  director, 
the  foreskin  was  loosened  from  the  glans  and  a  small  amount 
of  smegma  removed.  As  upon  retraction  the  opening  was 
found  to  be  too  small,  by  means  of  a  pair  of  scissors,  it  was 
clipped  along  its  dorsum  from  the  margin  of  the  foreskin  as 
far  up  as  the  edge  of  the  corona,  and  the  mother  was  instruct- 
ed to  retract  the  foreskin  daily,  so  as  to  prevent  its  readhering 
to  the  glans. 

The  surprise  of  the  author  may  well  be  imagined  when, 
upon  visiting  the  child  on  the  following  morning,  the  mother 
reported  that  the  baby  had  enjoyed  the  first  night's  sleep  of 
its  life,  and  had  manifested  an  appetite  for  its  breakfast,  a 
thing  heretofore  unknown  in  its  brief  history.  The  dropsy  in 
the  lower  extremities  was  also  perceptibly  reduced.  Medica- 
tion was  stopped  and  the  case  kept  under  observation  for  a 
week,  at  the  end  of  which  time,  as  it  was  sleeping  and  eating 
well  and  all  dropsical  symptoms  had  entirely  disappeared,  it 
was  dismissed  as  cured.  Two  weeks  later,  while  the  author 
was  still  pondering  upon  the  marvelous  influence  which  the 
condition  of  the  foreskin  seemed  to  exercise  upon  the  nutrition 
of  this  little  patient,  the  mother  of  the  child  summoned  the 
author  in  great  haste  for  the  relief  of  a  new  trouble  which 
had  set  in.  The  woman  was  beside  herself.  She  said  she  knew 
the  child  would  die;  that  nothing  could  be  done  for  its  relief 
and  she  only  wanted  a  doctor  as  a  means  of  consolation.  Xo 
intelligent  account  of  the  child's  condition  could  be  obtained 
from  the  mother,  and  when  the  author  entered  the  sick-room 
he  was  still  wondering  what  possible  turn  the  case  could  have 
taken  in  so  short  a  time.  Imagine  his  consternation  when  he 
beheld  the  little  boy  lying  upon  the  pillow  with  a  head  grown 
to  such  extravagant  proportions  as  to  distort  the  little  fellow's 
appearance  beyond  the  possibility  of  recognition  by  any  one 
who  had  previously  known  him.  The  dropsy  had  evidently 


ORIFICIAL  SURGERY.  39 

returned,  and  instead  of  appearing  in  the  lower  half  of  the 
body,  had  taken  the  form  of  hydrocephalus.  Everywhere  else 
he  was  emaciated,  but  his  head  was  enormous.  All  the  sutures 
of  the  skull  had  been  pressed  apart  so  far  that  a  finger  could 
be  laid  in  any  of  them  without  coming  in  contact  with  the 
margins  of  the  bones  entering  into  its  formation.  The  fore- 
head protruded  to  such  an  extent  that  the  eyes  seemed  deeply 
buried  under  its  projection.  The  child  had  no  power  even  to 
raise  its  head,  and  simply  tossed  it  from  side  to  side,  moaning 
pitifully.  The  mother  was  at  once  questioned  as  to  the  condi- 
tion of  the  foreskin.  She  said  it  was  all  right  and  refused  even 
an  examination.  Seeing,  however,  that  she  was  so  beside  her- 
self as  to  be  entirely  devoid  of  judgment,  the  author  requested 
her  to  leave  the  room  and  to  send  in  the  nurse.  Upon  exami- 
nation the  fact  at  once  became  apparent  that  the  mother  had 
failed  to  keep  the  foreskin  retracted  and  that  it  had  healed 
up  tighter  than  ever.  Once  more  it  was  loosened  from  the 
glans,  again  it  was  slit  along  the  dorsum,  and  this  time  cir- 
cumcision was  practiced,  and  the  parts  prevented  from  healing 
together  by  a  careful  stitching  of  the  mucous  membrane  to 
the  skin  around  the  entire  margin  of  the  wound.  The  benefi- 
cial effects  of  the  proceeding  speedily  began  to  be  noticeable. 
Absorption  of  the  cerebral  spinal  fluid  began  at  once,  and 
continued  until  at  the  end  of  two  weeks'  time  all  suggestion 
of  hydrocephalus  had  passed  away  and  the  child  was  once 
more  dismissed  as  cured.  This  time  the  recovery  was  per- 
manent. The  baby  became  a  boy,  and  the  boy  a  man,  and 
from  that  time  to  this  he  has  never  been  seriously  ill. 


CHAPTER  III. 

ORIFICIAL    SURGERY:    WHAT    IS    IT— FACT,    FAD 
OR  FANCYf 


LIBBIE    HAMILTON   MUNCIE,   M.   D.,   PH.   M. 


As  the  years  go  by  the  progress  of  medical  and  surgical 
science  is  brought  about  by  discoveries  which,  when  perfected, 
revolutionize  the  healing  art;  when,  however,  departures  are 


40  ORIFICIAL  SURGERY. 

made  from  accepted  dogmas  of  schools,  and  a  healer  finds  a 
new  way,  which  practice  proves  most  wonderfully  efficacious, 
this  healer  is  indeed  an  exception  to  the  rule  is  he  establishes 
his  results  without  unjust  criticism  from  those  who  should 
have  been  his  most  earnest  supporters. 

Dr.  E.  H.  Pratt,  after  months  of  satisfactory  practical 
application  of  his  philosophy,  first  publicly  demonstrated  the 
principle  and  theory  of  the  orificial  thought  in  the  senior 
lecture-room  of  the  Chicago  Homoeopathic  Medical  College, 
in  the  presence  of  the  students.  The  effect  of  the  presentation 
of  the  thought  was  so  energetic  that  in  the  three  weeks  of  the 
term  that  yet  remained,  sixteen  of  the  class  presented  them- 
selves for  the  application  of  orificial  methods  to  their  con- 
ditions. Some  were  suffering  from  headaches,  some  from 
dyspepsia,  some  from  insomnia,  some  from  spermatorrhea,  some 
from  constipation  and  some  from  general  malnutrition.  The 
success  of  the  work  upon  these  test  cases  was  such  as  to  win 
forever  the  good  will  of  the  undergraduates.  From  then  until 
now  the  surgical  clinic  of  the  college  has  been  conducted  as 
far  as  possible  upon  orificial  principles.  The  experience  here 
acquired,  with  that  at  the  largest  hospital  in  Chicago  (Cook 
County),  as  well  as  in  other  institutions,  but  confirms  in  every 
particular  the  foundation  principles  of  the  philosophy;  and 
had  not  our  experience  of  years,  coupled  with  that  of  fellow 
workers,  been  a  parallel  one,  had  not  the  practical  workings 
of  the  philosophy  been  so  marvelously  effective  in  the  treat- 
ment of  chronic  diseases,  I  would  not  feel  justified  in  asking 
your  attention  to  that  which  would  but  fascinate  with  theories, 
and  flatter  your  intelligence.  I  therefore  feel  it  an  honor  to 
have  the  privilege  of  presenting  to  you  that  help  for  chronic 
diseases  which  has  for  its  corner-stone  orificial  philosophy; 
that  which  is  not  antagonistic  to,  or  in  place  of,  but  a  great 
addition  to,  all  other  resources  of  the  medical  profession. 

The  facts  which  merit  attention  in  this  connection  are 
based  upon  anatomy,  physiology  and  pathology. 

It  is  well  known  that  we  have  two  nervous  systems,  the 
cerebro-spinal  and  the  sympathetic. 


OEIFICIAL  SURGERY.  41 

The  cerebro-spinal  system  furnishes  the  sensations  of  which 
we  are  conscious,  and  is  the  directing  power  of  the  voluntary 
muscles. 

The  sympathetic  nervous  system  is  that  force  which  is 
called  into  activity  from  the  moment  of  conception  until  death 
calls  the  mortal  to  his  long  home.  It  is  the  faithful  monitor 
that  never  sleeps.  It  keeps  the  machinery  of  life  going  in  our 
sleeping  as  well  as  during  our  waking  hours.  Its  activities 
extend  to  the  most  remote  and  minute  parts  of  the  body.  As 
has  been  truthfully  said,  "We  live  by  tubes."  The  peristaltic 
action  of  these  tubes  is  carried  on  under  the  stimulus  of  this 
wonderful  sympathetic  system,  and  the  result  is  digestion, 
circulation,  assimilation  and  nutrition.  Perfect  nutrition  is 
acknowledged  to  be  essential  to  perfect  vitality  of  a  part  or 
a  whole,  therefore  there  must  be  an  unhampered,  sympathetic 
force  for  the  maintaining  of  this  nutrition  and  this  brings  us 
to  the  fact  that  "the  problem  of  health  is  the  problem  of 
sympathetic  nerve  force,  and  the  problem  of  disease  is  the 
problem  of  sympathetic  nerve  waste;"  therefore  the  greatest 
economy  in  the  unnecessary  expenditure  of  this  nerve  force 
is  the  all-important  theme  for  the  consideration  of  the  medical 
profession. 

Dalton  in  his  "Physiology"  states  the  following:  "In 
experimenting  upon  the  sympathetic  nerves,  evidences  of 
sensibility  are  much  less  acute  than  that  manifest  by  the 
cerebro-spinal  nerves,  and  show  themselves  only  after  pro- 
longed application  of  the  exciting  cause." 

This  statement  demonstrates  that  these  are  intelligent 
nerves,  though  of  a  low  order  of  intelligence,  and  that  con- 
tinud  irritation  upon  any  mucous  membrane  will  inevitably, 
sooner  or  later,  induce  a  strictured  condition  of  the  tube  in- 
volved. Any  prolonged  muscular  action,  even  though  involun- 
tary, means  a  waste  of  strength  or  nerve  force,  and  enervates 
the  entire  sympathetic  nervous  system,  and  through  it  the 
cerebro-spinal,  reducing  the  vigor  of  circulation,  which  is  the 
beginning  of  all  pathological  conditions. 

It  has  been  shown  that  the  most  common  points  of  irrita- 
tion are  found  where  the  sympathetic  nerve  supply  is  most 


42  ORIFICIAL  SURGERY. 

abundant ;  that  is,  at  the  orifices  of  the  body,  and  especially  the 
lower  orifice.  The  cause  for  this  is  explained  when  we  think 
of  the  universal  gateways,  not  only  for  the  exit  of  effete  matter, 
but  the  gateways  of  new  life  as  well,  as  points  of  greatest 
friction,  and  that  the  circumstances  of  one's  life  may  greatly 
impair  these  parts. 

Orificial  surgery  means  the  surgery  of  the  lower  orifices 
of  the  body.  It  is  a  fact  that  dilatation  of  the  upper  orifices 
will  not  influence  respiration  or  the  capillary  circulation  of  an 
entire  body;  it  will  not  resuscitate  after  drowning,  or  from 
the  effect  of  an  anesthetic  or  shock.  On  the  other  hand,  most 
profound  results  are  obtained  in  these  cases  from  the  dilatation 
of  the  lower  orifices  and  especially  the  rectum ;  this  fact  proves 
conclusively  the  important  relation  these  orifices  bear  to  the 
important  functions  of  respiration  and  circulation,  and  through 
these  upon  all  organic  functions  and  conditions  of  nutrition. 
Some  have  been  so  short-sighted  as  to  suppose  that  orificial 
surgery  begins  and  ends  with  dilatation  of  the  sphincter  mus- 
cles; to  the  contrary,  it  is  necessary  to  keep  in  mind  that  this 
procedure  alone  may  in  some  cases  produce  more  irritation  of 
mucous  membrance,  and  more  contraction  of  sphincters  and 
more  pinched  nerves  and  tissues,  instead  of  less. 

Orificial  philosophy  teaches,  further,  the  removal  of  all 
points  of  iritation  from  the  lower  orifices  of  the  body  by  meth- 
ods that  produce  little  shock,  immediately  arousing  a  bettered 
nutrition  to  every  part  by  flushing  the  capillaries, — avoiding 
the  clamping  and  ligating  of  masses  of  tissues,  removing  of 
all  diseased  parts,  not  only  tying  but  encapsulating  all  the 
bleeding  points  in  surrounding  healthy  tissue,  leaving  no  de- 
nuded surfaces  to  granulate,  and  no  tissues  to  slough. 

That  the  advantage  of  these  principles  applies  not  alone 
to  cases  requiring  attention  at  or  through  the  lower  orifices, 
but  in  all  cases  requiring  abdominal  section,  is  a  fact  which 
has  now  become  established  beyond  the  possibility  of  successful 
controversy. 

That  Professor  Pratt  is  the  most  original  and  progressive 
surgeon  of  our  day  is  acknowledged  by  physicians  of  both 
schools  at  home  and  abroad.  If  he  had  done  no  more  than  to 


OKIFICIAL  SURGERY.  43 

teach  how  a  clampless,  ligatureless  and  comparatively  blood- 
less vaginal  hysterectomy  can  be  done,  how  abdominal  surgery 
can  be  done  without  leaving  pinched  tissues,  it  would  make 
the  greatest  revolution  in  the  art  of  surgery  next  to  the  aseptic 
methods. 

Scattered  through  a  number  of  text-books  can  be  found 
records  of  different  surgeons  who  have  enucleated  the  uterus 
through  the  vagina.  These  accounts  date  as  far  back  as  the 
first  century  of  the  Christian  era.  But  to  Dr.  Pratt  belongs 
the  first  public  record  of  extirpating  the  uterus  with  a  view 
to  the  avoiding  of  shock  incidental  to  the  use  of  clamps  or  of 
tying  blood  vessels  en  masse.  This  entirely  new  and  original 
method  has  met  with  success  to  the  extent  that  places  him  in 
the  foremost  ranks  as  a  benefactor  to  mankind. 

In  this  country  there  was  comparatively  little  known  of 
vaginal  hysterectomy  until  Dr.  Pratt  introduced  it,  after  which 
the  medical  journals,  for  a  season,  were  teeming  with  various 
phases  of  denunciation  of  the  operation ;  it  nevertheless  proved 
to  be  the  power  that  started  the  ball  rolling,  and  now  we  find 
many  surgeons  who  have  added  to  their  list  of  operations 
vaginal  hysterectomy,  although  many  of  them  follow  the 
French  and  German  systems,  using  clamps  or  ligatures  or,  in 
other  words,  placing  the  entire  broad  ligament  in  a  relentless 
grasp,  for  the  object  of  preventing  a  hemorrhage  from  one 
main  artery  which  may  easily  be  pushed  aside  without  sever- 
ing or,  if  necessary,  can  be  ligated  in  its  entirety  without  injury 
to  surrounding  tissues. 

If  the  sympathetic  nerves  could  resist  as  can  the  cerebro- 
spinal  when  irritated  on  the  surface  of  the  body,  the  surgeon 
would  not  dare  to  clamp  these  involuntary  tissues.  There  is 
now  a  better  way  shown  than  to  take  advantage  of  that  part 
of  the  system  which  simply  bears  uncomplainingly  for  a  time. 

It  is  not  long  since  pain  has  been  traced  from  nerve  to 
nerve  until  it  is  finally  located  at  the  starting  point  of  irrita- 
tion. Progressive  oculists,  thoracic  specialists  and  dermatolo- 
gists are  learning  that  they  can  not  expect  desired  results 
until  all  sympathetic  disturbances  have  been  relieved.  Neuro- 
logists here  and  there  are  acknowledging  that  reason  does  not 


44  ORIFICIAL  SURGERY. 

easily  become  dethroned  without  a  former  disturbance  of  the 
very  citadel  of  life — the  sexual  sphere.  It  has  been  stated 
by  one  of  large  experience  that  "a  lunatic  without  a  morbid 
rectum  or  genitals  is  an  anomaly."  This  should  be  sufficient 
to  lead  to  an  examination  of  the  pelvic  organs  of  every  case 
of  insanity,  and  that  by  an  expert  in  this  branch.  It  is  not 
consistent  or  thorough  to  diagnose  and  prognose  a  case  as 
insanity,  and  thus  to  consign  the  unfortunate  to  the  madhouse. 
I  venture  to  state  that  there  can  be  hardly  a  case  of  insanity 
produced  but  what  gives  a  history  of  orificial  irritation,  either 
objective  or  subjective. 

Experience  teaches  that  the  pudic  nerve  from  its  five 
principal  terminals  in  the  lower  orifices  of  the  body  is  the 
bearer  of  more  messages  of  discord  than  all  the  other  nerves 
combined.-"  There  is  not  only  a  disposition  to  have  their  own 
family  grievances,  but  to  get  the  neighborhood,  if  not  the 
whole  community,  in  an  uproar.  This  acknowledged  phy- 
siological conclusion  explains  why  Emmet's  operation  for 
lacerated  cervix  has  proved  in  some  cases  beneficial,  and  so 
useless  in  others.  He  had  not  discovered  that  an  irritated, 
sympathetic  nerve  terminal  in  one  part  of  the  system  could 
be  as  much  of  a  disturber  of  the  systemic  harmony  as  would 
an  irritated  terminal  in  another  part.  That  the  same  pencil 
of  sympathetic  as  well  as  cerebro-spinal  nerves  which  sup- 
plies the  cervix  is  also  distributed  to  the  rectum  and  external 
sexual  organs,  and  consequently  susceptible  to  irritation,  has 
not  been  long  considered.  Thus  may  be  explained  how  orifi- 
cial surgery  has  carried  to  ripe  development  the  work  that 
Addison  Emmet  began  fifty  years  ago. 

It  was  the  disappointing  results  in  several  cases  operated 
upon  for  lacerated  cervix,  where  diseased  rectums  were  left 
unattended,  that  led  us  to  the  investigation  of  the  orificial 
methods,  and  later  to  their  application  so  gratifying.  So 
much  beyond  our  most  sanguine  expectations  have  the  results 
proven,  that  it  requires  no  stretch  of  the  imagination  to  state 
that  orificial  surgery,  scientifically  applied,  points  the  way  to 
reach  and  cure  multitudes  hitherto  beyond  help. 


OBIFICIAL  SURGERY.  45 

The  advocates  of  orificial  surgery  do  not  claim  that  there- 
in is  offered  a  panacea  for  every  ill,  or  that  it  can  cure  under 
all  circumstances.  Failures  to  cure  always  have  been  and 
always  will  be  recorded,  but  under  consistent  pursuing  of 
reflexes  from  periphery  to  center  and  center  to  pheriphery, 
and  eradication  of  irritations  of  sympathetic  terminals,  failures 
will  be  less  frequent  than  under  any  method  heretofore  em- 
ployed ;  and  it  will  be  more  fully  realized  that  chronic  diseases, 
from  skin  troubles  to  insanity,  and  every  phase  of  malnutri- 
tion or  neurasthenia,  are  amenable  to  the  procedure  of  orificial 
surgery.  Many,  however,  will  be  found  whose  poor  tenements 
are  too  far  degenerated  to  be  reclaimed,  and  the  tenant-must 
seek  that  home  from  whence  none  return.  This  brings  us  to 
a  realization  of  physical  decay  or  organic  disease,  and  since 
long-continued  functional  disturbance  leads  to  organic 
changes,  and  irritation  leads  to  functional  disturbance,  the 
awake  physician  will  be  on  the  alert  to  eradicate  all  points  of 
irritation  at  their  earliest  appearance,  instead  of  waiting  until 
the  body  cries  out  in  distress  for  deliverance.  Therefore  the 
time  to  make  an  examination  and  operation  is  not  when  organic 
disease  has  been  established,  but  while  they  are  simply  in  the 
earlier  stages  of  functional  disturbances.  Every  organic  disease 
(barring  congenital)  is  of  slow  development,  is  an  evidence  of 
innervated  vitality  or  lessened  resistance-power  against  disease, 
and  must  first  exist  as  a  functional  disease.  It  does  not  come 
in  a  minute;  the  sympathetic  makes  a  strong  and  dilligent 
fight  against  it  until  it  can  hold  out  no  longer  and  is  marked 
by  defeat ;  therefore  the  best  way  to  prevent  organic  disease  is 
to  prevent  functional  disease,  and  the  way  to  prevent  func- 
tional trouble  is  to  keep  the  sympathetic  unburdened  and  un- 
hampered by  the  everlasting  naggings  that  are  produced  by 
the  lesser  or  greater  irritation  at  the  orifices  of  the  body — the 
gateways  to  the  centers  of  life.  Still  there  may  be  found  prac- 
titioners who  will  object  to  the  removal  of  rectal  papillae  and 
the  relieving  of  preputial  adhesions  in  the  young  woman  who, 
he  knows,  is  rapidly  passing  into  incurable  conditions. 

By  nature  these  methods  are  unpleasant  to  both  patient 
and  physician,  and  are  not  altogether  painless.  There  seems 


46  ORIFICIAL  SURGERY. 

to  be  nothing  to  recommend  it  to  popular  favor  but  the  results. 
"With  the  laity  it  has  won  a  reputation  to  the  extent  that  pa- 
ients  and  friends  often  become  so  enthusiastic  in  its  recommen- 
dation as  to  insist  upon  their  friends  receiving  its  benefits. 
Judging  from  the  number  of  orificial  surgeons  that  convene 
each  year  in  Chicago,  and  the  enthusiasm  they  manifest,  there 
seems  to  be  an  ever-increasing  demand  for  this  line  of  treat- 
ment from  the  people  in  almost  every  part  of  the  United 
States. 

Orificial  surgery  is  a  gift  from  God  to  suffering  humanity ; 
it  cannot,  therefore,  be  a  mere  fancy,  it  cannot  be  a  useless  fad  ; 
is  is  a  veritable  fact. 


CHAPTER  IV. 
A  PLEA  FOR  ORIFICIAL  SURGERY. 


LEONARD  PRATT,  M.  D. 


It  is  with  a  firm  conviction  of  the  value  and  importance  of 
this  special  surgical  work  in  the  true  physician's  legitimate 
sphere  of  action  that  I  am  pleased  with  this  opportunity  of 
urging  it  upon  your  attention. 

The  incurable  cases  of  chronic  diseases  are  known  to  be 
numerous.  Failures  to  permanently  cure  are  in  the  experience 
of  each  one  of  us.  They  are  common  to  all  physicians. 

Each  one  of  you  just  think  over  the  list  of  such  in  your 
own  circle  of  professional  acquaintances  and  notice  how  many 
you  can  call  to  mind.  Probably  a  large  number  of  these  are 
relieved  by  intelligent  prescriptions,  adapting  the  remedies  as 
nearly  as  possible  to  indications  in  accordance  with  our  natural 
law  of  cure.  Failures  to  cure  permanently  are  still  so  numer- 
ous that  each  physician  can  count  in  his  own  practice  a  score 
of  such. 

There  are  not  far  from  twelve  thousand  practitioners  of 
our  school  in  the  United  States,  and  if  each  one  has  but  a  few 
such  cases  what  a  vast  army  presents  itself. 


ORIFICIAL  SURGERY.  47 

Add  to  this  list  the  millions  resorting  to  nostrums  and 
quack  remedies,  and  the  vast  number  who  are  under  the  con- 
stant treatment  of  our  professional  brethren  of  the  other  school 
without  being  cured,  and  we  have  a  phalanx  of  invalids  which 
should  enlist  the  honest,  earnest  and  best  efforts  of  all  good 
physicians  to  devise  other  means  of  cure  where  our  present 
skill  proves  a  partial  or  entire  failure. 

Oriflcial  surgery  provides  a  happy  means  to  that  important 
object.  Its  claims  are  based  upon  results  well  established  by 
oft  repeated  experiences.  Properly  applied,  by  its  means  at 
least  three-fourths  of  this  vast  army  of  invalids  are  curable. 
Still  many  physicians  and  medical  organizations  turn  from  its 
just  claims  to  investigation  and  close  their  eyes  to  its  merits, 
plodding  on  in  the  old  beaten  paths. 

It  is  the  duty  of  every  true  physician  to  cure  the  sick  and 
afflicted.  This  should  be  the  exclusive  object  of  his  life's  work. 
He  is  morally  obligated  to  familiarize  himself  with  the  most 
effectual  means  of  accomplishing  that  noble  object. 

Otherwise  it  is  inconsistent  for  him  to  claim  to  be  a  phy- 
sician in  the  true  sense  of  the  word.  The  evidences  of  the 
truth  and  value  of  the  orificial  philosophy  and  the  happy  re- 
sults of  its  judicious  application  are  now  so  prominent  that 
the  profession  is  remiss  in  its  duty  and  obligations  when  it 
passes  by  its  just  claims  without  investigating  its  merits  and 
testing  its  curative  powers.  It  is  no  longer  mere  experiment. 
Its  philosophy  is  based  upon  facts  pertaining  to  pathology,  phy- 
siology and  anatomy.  Let  us  consider  it  briefly. 

After  food  is  introduced  into  the  aesophagus  we  all  know 
that  it  is  conveyed  into  the  digestive  organs,  digested,  absorbed 
into  the  circulation,  conveyed  to  the  capillary  vessels  of  each 
organ  of  the  body  from  which  the  organ  receives  and  appro- 
priates the  elements  necessary  to  perpetually  rebuild  the  waste 
caused  by  effete  cells  whose  duty  is  done ;  and  this  is  done  in- 
dependently of  any  exercise  of  volition  or  even  perception  on 
our  part. 

This  is  accomplished,  as  every  physician  knows,  by  the 
force  and  functional  power  of  the  sympathetic  nervous  system. 
The  circulation  of  the  blood,  the  secretion  and  excretion,  waste 


48  ORIPICIAL  SURGERY. 

and  repair  of  all  the  organs  of  the  body  are  carried  on  by 
means  of  peristalic  movements  through  tubular  structures. 
"We  know  that  these  structures  "are  supplied  with  a  muscular 
coat  whose  fibres  are  arranged  longitudinally  and  circularly 
so  that  by  their  alternate  contraction  and  relaxation  a  vermicu- 
lar motion  is  kept  up  by  means  of  which  solids  and  fluids  are 
propelled  along  their  various  channels."  These  functional 
activities  of  the  organism  are  presided  over  by  the  sympathetic 
nervous  system,  which  is  constant  in  its  work  whether  we 
sleep  or  wake,  rest  or  labor,  in  sickness  and  health. 

The  cerebro-spinal  system  sleeps  when  we  sleep,  and  var- 
ious causes  may  contribute  to  arrest  the  functional  power  of 
this  system — as  shocks,  faintings,  anaesthetics,  sleep,  etc. — but 
when  the  functional  power  of  the  sympathetic  nervous  system 
is  arrested  immediate  death  is  the  result.  Now,  inasmuch  as 
the  latter  system  controls  respiration,  circulation,  nutrition 
and  all  the  functions  of  waste  and  repair  constantly  going  on, 
it  follows  that  any  cause  which  weakens  the  nervous  force  thus 
supplied  will  so  far  make  the  various  organs  and  tissues  sus- 
ceptible to  morbific  changes.  The  power  of  reacting  against 
the  various  causes  of  disease  is  in  so  far  destroyed  as  this  force 
is  diminished.  You  see,  then,  the  question  of  health  is  really 
one  of  nerve  force.  This  force  holds  in  harmonious  activity 
and  union  all  the  physical  structures  which  it  supplies,  and 
when  organic  disease  is  developed  it  is  because  that  force  is 
so  weakened  that  it  cannot  control  the  capillary  circulation  of 
the  organ.  We  all  know  that  physical  health  is  entirely  de- 
pendent upon  the  proper  circulation  of  the  blood.  No  matter 
what  means  are  used  to  restore  health  to  diseased  organs,  they 
all  have  one  grand  object  in  view,  viz. :  to  restore  to  a  normal 
condition  the  circulation  of  the  blood.  When  that  is  accom- 
plished and  maintained  and  the  current  is  full  and  free, 
health  is  assured. 

When  the  general  circulation  is  poor  or  local  congestions 
occur  morbific  changes  at  once  set  in.  Blood  stasis  is  the  be- 
ginning of  all  pathological  changes,  and  the  great  problem  for 
us  to  solve  is  how  to  restore  a  normal  circulation  of  the  blood 
and  perpetuate  it.  To  solve  this  question  it  becomes  necessary 


OEIFICIAL  SURGERY.  49 

for  us  to  inquire  and  determine  where  the  causes  of  nerve 
waste  exist.  Orificial  philosophy  says,  "in  the  lower  orifices 
of  the  body."  Let  us  now  consider  how  this  is.  In  the  first 
place  the  proposition  laid  down  by  the  author  of  the  orificial 
philosophy  is  found  to  be  true,  viz. :  "  In  all  pathological  con- 
ditions, surgical  or  medical,  which  linger  persistently  in  spite  of 
all  efforts  at  removal,  from  the  delicate  derangements  of  brain 
substance  that  induce  insanity,  and  the  various  forms  of  neur 
asthenia,  to  the  great  variety  of  morbid  changes  repeatedly 
found  in  the  coarser  structures  of  the  body,  there  will  invar- 
iably be  found  more  or  less  irritation  at  the  rectum,  or  the  ori- 
fices of  the  sexual  system,  or  both.  In  other  words,  there  is 
one  predisposing  cause  for  all  forms  of  chronic  disease,  and 
that  is,  a  sympathetic  nerve  waste  occasioned  by  orificial  irri- 
tation at  the  lower  openings  of  the  body."  This  has  been  con- 
firmed by  close  observation  by  thousands  of  physicians  since 
its  promulgation.  The  testimony  is  unanimous  that  whenever 
a  case  of  chronic  disease  exists,  persistent  in  its  nature,  resist- 
ing all  common  means  adopted  for  its  cure,  there  is  always 
found  irritation  at  some  one  of  these  orifices.  It  is  legitimate 
and  appropriate  to  ask,  how  is  it  that  irritation  there  wastes 
and  exhausts  the  force  and  power  of  the  sympathetic  nerve, 
the  integrity  of  which  is  so  necessary  for  good  health? 

The  limits  of  the  present  paper  will  not  permit  a  considera- 
tion of  all  the  lower  orifices,  and  so  we  will  take  simply  the 
rectum  for  purposes  of  illustration.  "We  find  two  distinct 
sphincter  muscles — external  and  internal.  They  are  situated 
one  to  one  and  a  half  inches  apart.  The  upper  one,  being  an 
involuntary  muscle,  is  supplied  with  nerves  from  the  sympathe- 
tic nervous  system.  This  is  true  in  relation  to  the  fibres  of  all 
involuntary  muscles. 

The  external  sphincter,  being  more  or  less  under  the  con- 
trol of  the  will,  takes  its  supply  of  nerves  from  the  cerebro- 
spinal  system.  Irritation  of  these  muscles  or  between  them 
causes  an  involuntary  contraction  of  the  fibres,  especially  of 
the  internal  one,  and  constant  spasmodic  contraction  is  what 
wastes  the  functional  power  of  the  sympathetic  nerve  in  such 
a  manner  as  to  permit  organic  disease  to  develop  without  suffi- 


50  ORIFICIAL  SUBGERY. 

cient  nerve  force  to  throw  it  off.  It  is  well  known  that  spasm 
of  any  muscle,  either  voluntary  or  involuntary,  is  very  prodi- 
gal of  nerve  force.  If  you  steadily  contract  any  voluntary 
muscle  the  evidence  of  this  will  soon  manifest  itself. 

This  is  easily  demonstrated  by  experiment.  Hence  it  is 
that  the  constant  contraction  of  muscles  composed  of  involun- 
tary fibres  caused  by  morbid  conditions  of  the  rectum  rapidly 
exhausts  the  nerve  force  which  supplies  them.  Now,  as  men- 
tioned, it  is  this  sympathetic  nerve  force  which  controls  nu- 
trition and  the  capillary  circulation  of  the  entire  organism; 
we  see  at  once  that  the  health  of  the  various  organs  and  their 
harmonious  activity  depend  entirely  upon  the  integrity  of  this 
sympathetic  nerve  force.  Normal  power  and  activity  of  this 
force  mean  a  healthy  organism.  Weaken  this  force  and  the 
whole  physical  machinery  is  liable  to  get  out  of  repair.  It 
takes  away  the  reactive  power  of  the  system  to  ward  off  active 
causes  of  disease.  The  power  of  the  "vis  medicatrix  naturae" 
is  thus  diminished,  making  restoration  to  health  more  difficult. 

Response  to  the  action  of  appropriate  remedies  is  more 
tardy  and  many  times  it  fails  utterly. 

Clonic  spasms  of  involuntary  muscular  fibres  are  very 
disastrous  in  their  effects  upon  the  organism,  and  the  feeble- 
ness of  nerve  exhaustion  thus  induced  shows  itself  chiefly  in 
functional  disorders,  and  they  are  the  voices  liable  to  be  misun- 
derstood. They  do  not  call  directly  to  the  cause  which  secretly 
does  its  effective  work.  Long  continued  contraction  of  volun- 
tary muscular  fibres  talks  in  direct  and  unmistakable  lan- 
guage. It  points  directly  to  the  cause  of  suffering  thus  induced. 

But  many  cases  of  serious  functional  disease  are  caused  by 
the  weakening  effect  upon  the  sympathetic  nerve  of  spasms  of 
the  involuntary  muscular  fibres  of  the  sphincter  muscles  when 
the  local  irritation  has  not  been  sufficient  to  annoy  the  patient. 
Hence,  often  a  suggestion  that  a  secret  cause  may  exist  there 
is  treated  as  very  improbable  and  even  an  examination  not 
allowed  on  account  of  such  a  conviction.  In  most  of  such 
cases  subsequent  investigation  and  treatment  have  confirmed 
the  suspicion  of  local  irritation,  and  removal  of  its  cause  has 
been  the  means  of  a  permanent  cure  of  functional  disorders. 


OEIPICIAL  SUEGERY.  51 

These  functional  disorders  at  times  are  marked  and  violent 
while  the  orificial  irritation  may  be  so  slight  as  not  to  be  no- 
ticed by  the  patient. 

Such  cases  are  often  relieved  at  once  by  simply  stretching 
the  sphincter  ani.  A  typical  illustration  of  cases  of  this  nature 
is  mentioned  by  Dr.  "Win.  T.  Helmuth,  of  New  York,  in  the  dis- 
cussion of  an  article  on  orificial  surgery  presented  by  Dr.  E.  H. 
Pratt,  at  the  meeting  of  the  International  Congress  held  in 
Atlantic  City,  N.  J.,  last  June.  His  experience  in  orificial 
surgery  has  been  very  limited  and  he  professes  to  know  but 
little  about  it.-  He  says,  "the  little  that  I  do  know  about  this 
method  has  been  extremely  satisfactory  to  me.  I  cannot  say, 
for  I  do  not  know,  that  by  means  of  orificial  surgery  almost 
every  disease,  including  insanity,  may  be  cured,  nor  do  I  know 
from  personal  experience  how  extensively  these  reflexes  affect 
other  diseases  mentioned  by  Dr.  Pratt,  but  when  any  member 
of  this  Intsitute  stands  in  his  place  and  details  his  experience 
we  are  bound  to  investigate  and  believe  him,  or  those  who 
know  to  the  contrary  should  arise  and  contradict  him.  For 
myself  I  can  only  say  that  a  case  of  the  most  persistent  vomit- 
ing in  a  young  lady  came  under  my  care.  She  had  been  under 
both  systems  of  practice,  and  I  had  tried  all  the  remedies 
which  I  knew.  It  was  doubtless  a  case  of  hysterical  emesis. 
In  desperation  I  suggested  that  the  sphincter  ani  be  stretched ; 
it  was  thoroughly  done,  and  she  has  not  vomited  from  that  time 
to  this.  I  had  another  patient  upon  whom  I  operated  after- 
ward for  a  nephrotomy,  opening  the  kidney  and  allowing  large 
quantities  of  pus  to  drain  off.  This  gentleman  was  well  known 
in  the  west,  and  suffered  such  terrible  spasmodic  action  of 
his  bladder,  that  every  hour  and  a  half,  all  night  and  all  day, 
he  would  be  troubled  with  such  a  severe  urinary  tenesmus 
that  his  life  was  a  burden.  The  introduction  of  the  catheter, 
opium  suppositories,  belladonna,  hyoscyamus,  pichi,  canthar- 
ides,  and  even  the  introduction  of  the  rectal  tube  for  a  time 
was  tried  without  avail.  Then  I  stretched  his  sphincters  with 
immediate  and  permanent  relief  of  these  distressing  symp- 
toms. I  state  these  things  simply  to  uphold  Dr.  Pratt  on  one 
portion  of  his  paper. 


52  OBIPICIAL  SURGERY. 

' '  Of  the  rationale  of  these  nervous  reflexes  as  yet  we  know 
very  little,  but  the  facts  remain  that  the  practice  of  orificial 
surgery  as  applied  to  the  rectum  and  lower  orifices  of  the 
body  is  often  followed  by  the  most  remarkable  results.  We 
know  when  we  relieve  phimosis  how  many  different  nervous 
conditions  are  instantly  removed." 

Dr.  Storke  at  the  same  congress  observes  that  although  he 
is  not  a  surgeon  of  any  special  school,  he  claims  to  have  had 
opportunities  to  observe  the  effects  of  ^orificial  surgery.  He 
mentions  one  patient,  "an  old  time-worn  minister,  who  had 
suffered  from  very  severe  mental  symptoms,  nervous  depres- 
sion, exhaustion,  poor  digestion  and  rectal  troubles  until  his 
life  was  unbearable  to  him.  He  had  passed  through  the  hands 
of  many  physicians  without  any  benefit.  I  was  able  to  afford 
him  but  little  relief,  and  simply  prescribed  for  him  from  day 
to  day  with  slight  pallation.  He  passed  into  the  hands  of  one 
of  Dr.  Pratt 's  pupils,  who  found  that  there  was  an  irritable 
condition  of  the  sphincters,  some  slight  inflammation  of  the 
rectal  mucous  membrane  and  a  little  discharge  of  pure  white 
mucus.  The  sphincters  ani  were  thoroughly  stretched,  and 
with  that  one  operation  disappeared  every  vestige  of  the  old 
man's  sickness.  T  had  an  opportunity  of  observing  him  for 
some  months  after  that  operation,  and  to  my  certain  know- 
ledge he  was  as  well  as  any  man  of  sixty-five  years  of  age 
could  expect  to  be.  After  the  stretching  this  patient  took 
no  medicine." 

Dr.  Skiles,  at  the  same  meeting  after  this  work  had  been 
referred  to  during  the  discussion  as  curative  in  almost  every 
conceivable  nervous  trouble — sympathetic  nervous  trouble — 
said:  "It  doesn't  seem  to  make  any  difference  what  kind  of 
a  nervous  trouble,  whether  it  is  paralysis,  whether  it  is  neu- 
ralgia or  insanity.  Now  this  seems  like  a  very  broad  statement 
to  us,  and  when  I  first  heard  of  this  method  of  Dr.  Pratt 's  I 
didn't  believe  a  word  of  it;  in  fact  I  fought  it  as  best  I  knew 
how.  I  can  best  illustrate  this  by  telling  you  how  I  came  to 
believe  it.  I  had  a  patient,  a  consumptive,  a  lady  whom  I 
expected  to  die  in  from  ten  days  to  two  weeks.  The  most 


ORIFICIAL  SURGERY.  53 

tormenting  thing  she  had  was  a  diarrhoea.  As  you  all  know, 
this  is  very  tormenting  in  the  last  stages  of  consumption.  A 
young  physician  who  was  then  watching  Dr.  Pratt 's  experi- 
ments, five  years  ago  last  winter,  told  me  one  day  that  I  could 
cure  that  diarrhoea  if  I  would.  I  said  at  once,  'do  you  think 
that  thing  of  Pratt 's  would  cure  that  trouble?'  He  said  he 
did.  I  said  to  him,  'here  is  ten  dollars.  Go  down-town  and 
get  the  necessary  instruments  and  we  will  operate.'  Next 
morning  we  gave  the  patient  some  chloroform,  snipped  out 
two  or  three  papillae  and  some  pockets,  and  within  three  days 
the  diarrhoea  stopped,  and  my  patient  lived  several  weeks  in 
comfort.  Since  that  time  I  have  been  a  thorough  believer  in 
orificial  surgery.  I  can  assure  you,  too,  that  I  have  relieved 
paralysis,  complete  hemiplegia,  running  twelve  months.  I 
can  also  assure  you  that  I  have  relieved  insanity  quite  a  num- 
ber of  times;  one  case  particularly  would  be  of  interest.  This 
case  was  of  a  lady  twenty-eight  years  of  age  who  had  pro- 
found melancholia.  Of  course  you  all  know  that  is  the  hardest 
kind  to  treat.  These  violent  cases  of  insanity  in  a  great  many 
cases  get  well  spontaneously,  but  never  the  melancholias.  In 
this  class  of  cases  it  is  my  custom  to  put  them  under  chloroform 
and  see  if  there  is  not  some  cause  for  the  trouble  beside  the 
organic  trouble  of  the  brain.  She  could  not  utter  one  single 
sentence.  A  word  or  two  she  could  utter,  but  with  great 
difficulty.  I  found  that  the  rectum  was  ulcerated;  that  the 
uterus  was  ulcerated,  retro  verted  and  lacerated;  that  the 
urethra  was  carnucled.  I  though  any  one  of  these  was  enough 
to  produce  her  mania.  I  treated  this  lady  every  ten  days, 
under  chloroform,  for  three  months;  at  the  end  of  that  three 
months  I  had  the  rectum  in  healthy  condition,  the  uterus  in 
a  normal  position,  the  ulceration  was  gone  and  the  bladder 
was  in  a  healthy  condition.  Still  she  could  not  talk  nor  could 
she  utter  one  single  clear  thought.  We  still  had  the  lacera- 
tions. I  told  the  husband  there  was  one  thing  to  do,  namely, 
repair  the  laceration,  believing  that  this  was  enough  to  pro- 
duce the  congestion  of  the  brain  so  that  she  could  not  talk. 
The  following  day  I  repaired  it  under  chloroform,  and  to  my 


54  ORIPICIAL  SURGERY. 

profound  delight  when  she  came  out  from  under  the  chloro- 
form she  was  in  her  normal  right  mind,  and  she  has  remained 
so  ever  since.  And  this  was  fourteen  months  ago." 

There  are  members  of  this  society  who  could  relate  many 
remarkable  results  in  their  practice.  Your  humble  servant 
could  write  a  volume  of  his  experiences  in  the  past  five  or 
six  years  showing  results  of  this  work  marvelous  and  in  some 
cases  almost  incredible. 

In  many  of  the  eastern  and  some  of  the  southern  and 
western  states  there  are  now  thousands  of  able  physicians 
whose  testimony  confirms  the  value  and  importance  of  orificial 
surgery.  It  is  not  a  substitute  for  other  treatment.  It  simply 
supplies  a  foundation  for  skillful  treatment  to  cure  many  cases 
otherwise,  so  far  as  we  know,  incurable. 

This  method  is  not  advised  except  in  cases  where  other 
means  fail  to  cure.  Of  this  class  of  cases  fully  three-fourths 
can  be  brought  into  a  state  of  reasonably  good  health  by 
its  methods.  Does  not  this  furnish  good  ground  for  a  plea 
in  its  favor? 

It  is  known  to  some  of  our  members  that  in  September, 
1888,  a  Society  of  Orificial  Surgeons  was  organized  in  the  city 
of  Chicago.  This  society  now  numbers  several  hundred  phy- 
sicians from  all  over  the  United  States.  Its  reports  confirm 
the  position  taken  in  this  paper  of  the  inestimable  value  of 
its  methods.  The  Sanitarium  at  Chicago,  now  having  one 
hundred  and  forty  rooms  which  are  filled  most  of  the  time, 
has  been  running  about  two  years  successfully,  and  its  reports 
are  very  flattering  as  to  the  results  of  orificial  surgery.  Pre- 
vious to  the  erection  of  this  building  patients  were  accom- 
modated at  hotels,  private  boarding-houses  and  two  buildings 
fitted  up  which  were  soon  too  limited  to  accommodate  all  the 
patients.  Nine  medical  colleges  teach  its  philosophy  in  their 
curriculums.  Our  college  here  should  not  hesitate  to  teach 
and  test  its  utility. 

It  should  be  introduced  into  our  hospitals.  I  firmly  be- 
lieve that  more  than  half  of  the  cases  of  insanity  in  our 
asylums  can  be  cured  by  skillful  orificial  surgery  used  as  a 
foundation  for  judicious  treatment  afterward.  Experience 


ORIFICIAL  SURGERY.  55 

and  reports  of  many  reliable  physicians  supply  a  good  basis 
for  this  confidence. 

In  all  earnestness  I  ask  each  physician  of  all  schools  to 
give  this  method  his  deliberate  consideration.  Submit  it  to 
the  only  true  test  of  any  method  of  practice.  Learn  its 
methods  thoroughly  and  apply  them  skillfully.  You  will  then 
realize  astonishingly  happy  results.  Why  not  do  this?  Take 
the  cases  you  fail  to  cure  otherwise.  No  harmful  results  follow 
the  work  when  properly  done.  The  testimony  in  its  favor  is 
overwhelming.  Can  you  be  justified  in  withholding  your 
attention  from  a  method  which,  with  good  grounds,  promises 
to  do  so  much  where  other  means  fail  ?  It  will  have  its  failures. 
Is  this  surprising  when  you  view  the  class  of  cases  submitted 
to  this  surgical  work,  viz.,  the  incurables,  and  yet  more  than 
half  of  these  are  restored  to  a  reasonable  degree  of  good  health 
and  of  course  made  happy  in  the  enjoyment  of  home  and 
society  ? 

The  list  of  chronic  diseases  to  which  this  work  is  applic- 
able is  a  long  one.  I  mention  a  few  of  them.  Diseases  of 
women,  bronchitis,  derangements  of  the  stomach  and  bowels, 
dyspepsia,  asthma,  spinal  irritation,  nervous  prostration, 
eczema,  kidney  and  liver  diseases,  dropsy,  neuralgia,  paralysis 
— in  short  all  chronic  maladies  which  resist  other  skillful 
treatment.  Even  cancer  is  much  benefited  by  the  work  because 
it  equalizes  nervous  force  and  the  capillary  circulation. 

It  is  the  invalid 's  firm  friend  and  should  be  used  skillfully 
as  the  physician's  chief  reliance  when  other  means  of  cure 
fail. 

Again  my  plea  is  that  you  investigate  and  test  its  merits. 


CHAPTER  V. 
ORIFICIAL  SURGERY. 


W.   E.   BLOYER,   M.   D. 


We  will  not  attempt  in  this  paper  to  give  an  exposition 
of  the  orificial  philosophy.  It  has  too  much  breadth,  too  much 
depth,  too  much  general  scope,  to  bring  it  within  the  confines 


56  ORIFICIAL  SURGERY. 

of  a  society  paper.  It  has,  however,  been'thus  briefly  stated: 
"All  chronic  diseases,  surgical  or  medical  in  character,  are 
due  to  irritation  at  the  lower  orifices,  causing  nerve  waste." 

To  many,  no  doubt,  such  a  declaration  may  seem  too 
broad,  too  sweeping,  too  comprehensive;  it  may  seem  illogical, 
unreasonable,  or  to  border  upon  presumption. 

Certainly  we  are  not  now  all  prepared  to  accept  such  a 
statement  in  its  totality  or  as  being  literally  true.  It  favors 
too  much  the  expression  of  the  ordinary  "cure-all."  But  as 
liberal-minded  men,  and  as  physicians,  ready  and  willing  to 
learn — to  get  good  from  any  and  all  sources — the  whole  phi- 
losophy should  not  be  condemned  because  we  cannot  encompass 
or  comprehend  this  brief  expression  of  it. 

Some  of  us  have  gradually  learned  to  appreciate  the  fact 
that  there  is  much  truth  in  the  orificial  philosophy,  and  we 
have  been  brought  to  a  realization  of  this  fact  by  accepting 
in  an  unbiased  way  the  results  of  so-called  orificial  surgery. 
The  further  fact  that  such  surgical  attention  paid  to  the  lower 
orifices  of  the  body  in  correcting  and  smoothing  them  does 
not,  in  every  case,  remove  (or  has  not  removed)  every  vestige 
of  disease  from  the  person  so  operated  upon,  should  not  lead 
to  the  condemnation  of  the  whole  idea,  because  the  operation 
may  have  been  imperfectly  done,  the  cause  may  not  have  been 
reached,  or  many  other  vital  conditions  may  have  been  vio- 
lated, or  the  orificial  principles  may  not  have  been  given  proper 
consideration.  For  instance,  one  would  hardly  expect  to  cure 
a  chronic  headache  due  to  eye-strain  by  orificial  procedures, 
nor  would  it  be  within  ordinary  reason  to  expect  to  cure  a 
bronchitis,  or  a  pneumonia,  or  an  influenza,  at  once,  by  a  trach- 
elorrhaphy  or  a  removal  of  the  prepuce,  or  a  dilatation  of  the 
sphincters. 

Within  our  own  individual  experience  results  have  cer- 
tainly been  very  satisfactory,  although  we  feel  that  we  have 
not  pressed  the  work  to  its  limit  by  any  means.  The  orificial 
surgeon  should  be  a  general  surgeon.  He  should  fully  under- 
stand and  appreciate  the  principles  of  surgery.  More  than 
this :  He  should  be  a  physician,  and  combine  with  his  orificial 
methods  the  means  and  armamentarium  at  the  command  of 


ORIFICIAL  SURGERY.  57 

the  observing  practitioner  of  medicine.  We  would  not  make 
of  orificial  surgery  a  special  surgery,  but  rather  an  adjunct 
to  both  medicine  and  surgery. 

It  is  hardly  necessary  to  call  the  attention  of  the  members 
of  this  society  to  the  ease  and  certainty  with  which  the  very 
centers  of  life  can  be  touched  through  the  lower  orifices  of 
the  body.  No  matter  how  profoundly  your  patient  be  under 
the  influence  of  an  anaesthetic;  he  may  be  so  unconscious 
that  a  knife-thrust  at  any  point  upon  body  or  limb  will  not 
in  the  least  disturb  the  eerebro-spinal  nervous  system  into 
the  slightest  expression  of  pain.  In  fact,  the  abdomen,  chest, 
or  cranium  can  be  opened,  the  most  vital  parts  and  organs 
touched,  cut,  or  excised,  and  there  will  not  be  the  least  mani- 
festation of  consciousness.  The  patient,  as  far  as  consciousness 
is  concerned,  seems  absolutely  dead.  Yet,  while  he  is  in  this 
condition,  if  a  rectal  speculum  be  introduced  into  the  anal 
outlet,  and  its  blades  separated,  there  are  immediately  not  only 
expressions  of  pain;  but  an  evident  serious  disturbance,  if  not 
a  sudden  cessation  in  the  action  of  the  heart  and  the  respira- 
tion. The  operator,  armed  with  this  knowledge,  has  always 
at  his  command  the  means  to  revive  the  patient  that  is  about 
to  succumb  to  the  depression  due  to  anesthesia.  Chloroform 
narcosis  has  been  robbed  of  many  victims  by  the  immediate 
and  thorough  dilatation  of  the  sphincters  surrounding  the  end 
of  the  bowel.  No  demonstration  could  be  clearer  or  more 
conclusive.  Through  these  points  the  great  sympathetic  nerv- 
ous system — the  the  vegetative  system  of  nerves — the  nerves 
of  the  body  that  never  sleep,  day  or  night — the  nerves  that 
attend  to  the  breathing,  the  circulation  of  the  blood,  the  diges- 
tion of  the  contents  of  the  alimentary  tract — the  nerves  that 
tear  down  and  build  up  the  tissues  of  the  body  in  conformity 
to  the  unfathomable  laws  of  life,  and  are  always  at  work,  even 
while  conscious  man  sleeps — the  nerves  that  anesthesia  itself 
does  not  anesthetize — can  be  impressed  through  their  exposed 
orperipheral  terminations  at  the  lower  outlets  of  the  body. 
We  are  positive  of  this;  nothing  is  more  certainly  proven. 
Thus  the  first  step  towards  the  orificial  philosophy  has  been 
made. 


58  ORIFICIAL  SURGERY. 

We  must  next  necessarily  know  when  these  nerves  need 
to  be  impressed — their  expressions  of  pathology — how  they 
should  be  impressed — whether  there  is  excess,  defect,  or  per- 
version of  their  actions,  and  how  or  by  what  means  or  man- 
ipulations— surgical  procedures,  if  you  please — the  existing 
wrongs  can  be  righted. 

The  absolute  truths  now  known  or  recognized  by  physi 
cians  and  surgeons  relative  to  the  orificial  idea,  are  of  recent 
discovery.  The  whole  philosophy  is  not  yet  known—not  yet 
developed — and  years,  perhaps  decades,  may  pass  before  ori- 
ficial surgery  will  have  been  fitted,  as  it  were,  for  the  niche  in 
the  wall  of  human  knowledge,  of  which  it  is  undoubtedly  a 
part.  Observation  and  trial,  and  time,  will  eventually  de- 
velop it. 

But  no  matter  how  much  truth  and  science  there  is  in  the 
orificial  philosophy,  it  is  at  all  times,  like  so  many  other  things 
in  close  relation  to  medicine  and  surgery,  subject  to  the  ever- 
varying  complications  and  conditions  of  the  patient — to  his 
physical  inheritance,  to  his  circumstances,  and  to  his  environ- 
ment. However,  from  our  observations,  based  upon  our  own 
experience  and  that  of  others,  the  results  of  orificial  treatment 
are  many  times  astonishingly  favorable,  and  we  may  say  al- 
ways satisfactory,  when  the  work  has  been  properly  done. 

A  few  cases  coming  under  our  own  observation  may  help 
bring  to  the  orificial  idea  the  favorable  opinion  that  may  lead 
to  its  thorough  investigation  that  we  so  much  desire.  The. 
sooner  it  rises  to  the  height,  or  falls  to  the  depth,  to  which 
its  merits  consign  it,  as  is  determined  by  the  physician  in 
active  practice,  the  better  will  it  be  for  the  profession  and 
humanity. 

Mrs.  A.,  married  five  years,  had  been  pregnant  once 
within  the  last  year,  but  aborted  about  the  end  of  the  second 
month.  Her  menstrual  periods,  though  fairly  regular,  were 
fraught  with  the  most  intense  pains  and  nervousness.  For  a 
week  or  ten  days  in  each  calendar  month  she  was  unable  to  be 
out  of  bed.  The  remainder  of  the  month  her  stomach  was  a 
disturber;  her  tongue  was  always  covered  with  a  white  fur, 
and  the  relish  of  food  was  wholly  unknown  to  her.  She  ate 


ORIFICIAL  SURGERY.  59 

her  meals  in  a  sort  of  mechanical  way — simply  because  she 
thought  she  should  eat  them,  and  not  because  she  enjoyed 
them  in  the  least.  In  consequence  of  these  troubles,  she  was 
thin  in  flesh,  sallow  if  not  yellow,  constipated,  weak,  peevish, 
nervous — a  burden  to  herself  and  her  friends.  She  had  suf- 
fered many  things  of  many  physicians.  Pills,  powders,  po- 
tions of  all  kinds,  had  been  tried  and  always  without  favorable 
results. 

With  the  assistance  of  two  of  my  colleagues — respected 
members  of  this  Association — but  not  until  the  ordinary  medi- 
cal measures  had  been  exhausted,  orificial  methods  were  used 
upon  her.  The  clitoris  was  "unhooded, "  and  smegma,  that 
had  perhaps  been  secreted  and  prevented  from  escaping,  from 
the  time  of  her  birth,  in  abundance  was  turned  out.  Her  ure- 
thra was  small,  irritable,  and  ragged,  and  a  small  caruncle  pre- 
sented. It  was  trimmed  smoothly  and  dilated.  The  external 
os  uteri  was  "pin  hole."  The  cervical  canal  small,  sinuous. 
The  endometrium  was  tender  and  covered  by  granular  excre- 
scences. The  os  and  canal  were  dilated.  The  cavity  carefully 
but  thoroughly  curetted  and  then  mopped,  so  that  neither 
debris  nor  clotted  blood  remained  in  it  to  become  a  nidus  for 
septic  troubles.  The  sphincter  ani  was  close  and  extremely 
strong.  The  rectal  speculum  revealed  some  pockets  and  papil- 
lae. They  were  all  removed,  and  the  sphincters  thoroughly 
dilated,  if  not  divulsed. 

After  twenty-four  hours,  when  the  chloroform  sickness 
had  been  overcome,  she  expressed  herself  as  feeling  somewhat 
sore  locally,  but  mentally  she  was  calm,  serene,  easy — upon  an 
altogether  different  nervous  plane.  The  tension  had  been 
taken  off,  and  she  was  let  down  to  her  natural  self.  I  need 
hardly  tell  you  that  the  dysmenorrhea  is  no  more.  The  stom- 
ach and  digestive  tract  act  as  a  good  stomach  and  digestive 
tract  should.  The  constipation  is  gone,  her  sallowness  is  gone. 
She  hardly  seems  the  same  woman ;  in  fact,  she  is  not  the  same 
woman.  Her  predecessor  was  nervous,  high  strung,  half  wild, 
hysterical,  both  day  and  night.  This  woman  is  cool,  quiet,  and 
unconcerned. 


60  OBIFICIAL  SURGERY. 

Had  not  the  change  been  wrought,  Doctor,  aould  you  tell 
where  her  nervousness  would  have  carried  her?  Do  not  our 
asylums  contain  many  whose  troubles  began  as  hers?  Would 
medicine  alone  have  wrought  the  change? 

"Was  called  to  see  a  scrawny,  milk-and-water  looking  boy. 
His  father  said,  "Doctor,  take  Joe,  and  look  him  over.  He 
sleeps  badly,  is  restless,  uneasy,  dreamy.  He  eats  poorly  his 
appetite  is  vicarious  and  morbid  or  many  times  he  eats  noth- 
ing. He  looks  bad,  he  complains  of  vague  pains,  and  he  ivets 
the  bed  nearly  every  night."  Everything  in  his  make-up  pointed 
to  a  lack  or  waste  of  sympathetic  nerve  force.  1  at  once  said. 
"Let  me  see  that  foreskin."  Here  it  was,  a  half  or  three- 
quarters  of  an  inch  too  long,  with  a  very,  very  small  opening, 
so  small  that  when  an  effort  was  made  to  retract  it,  only  a  small 
red  point  on  the  glans  penis  could  be  made  to  peep  through. 
Said  I,  "Here  is  the  trouble.  Get  rid  of  this,  and  your  boy 
will  be  better,  if  not  well. ' '  We  not  only  amputated  that  fore- 
skin, but  we  dissected  strong  adhesions  where  it  was  attached 
to  the  glans  penis.  When  loose,  rolls  of  smegma,  like  pencils 
of  butter,  were  set  free.  The  sphincters  were  stretched,  and 
the  result  was  like  magic.  The  orificial  treatment  was  to  this 
boy  the  "open  sesame"  from  a  poor  life  to  a  new  life.  Today 
he  is  becoming  red-faced,  chubby — the  picture  of  health.  The 
bed-wetting,  the  restlessness,  the  vague  pains,  the  poor  diges- 
tion and  appetite  are  gone,  and  gone  forever. 

Another — Mrs.  R.,  married,  though  a  woman  of  good  flesh 
and  appetite,  was  restless,  nervous,  and  barren.  She  had  had 
many  physicians,  but  she  received  little  aid.  An  examination 
revealed  a  tightly-hooded  clitoris,  a  caruncle  of  no  mean  size 
in  the  urethra,  and  a  "pin-hole"  os.  All  of  these  were  at- 
tended to  and  the  result  was  magical.  She  was  transformed. 
The  cold,  lifeless,  unfeeling  sexual  embrace  gave  way  to  a  feel- 
ing that  we  fear  salix  nigra  would  not  suppress.  The  tantaliz- 
ing urinary  disturbances  are  no  more.  Menstruation  is  free, 
easy,  regular,  and  there  is  hope  that  the  much-desired  and  long- 
sought-for  pregnancy  will  come.  In  short,  she  is  now  a  well 
woman,  and  enjoys  life  to  the  fullest  extent  of  the  word. 


OEIFICIAL  SURGEKY.  61 

Scores  of  cases  could  be  reported  in  which,  the  attention 
to  these  minor  matters  was  to  the  patient,  as  it  were,  a  new 
creation,  if  not  a  new  birth. 

"We  ask  the  members  of  this  society  to  give  this  orificial 
idea  some  attention.  It  will  not  cure  everybody  of  every  dis- 
ease ;  but  help  humanity  by  helping  the  profession  to  find  out 
and  to  know  exactly  what  it  will  do,  and  to  place  it  in  the 
sphere  in  which  it  belongs. 


CHAPTER  VI. 
ORIFICIAL  SURGERY. 


O.    S.    RUNNELS,    A.   M.,   M.    D. 


I  desire  to  consider  today  the  general  subject  of  orificial 
surgery.  I  wish  to  do  so,  not  as  a  partisan,  but  as  a  scientific 
physician,  intent  only  upon  the  recognition  of  truth.  In  science 
all  personal  equations  are  ruled  out ;  all  parties  and  cliques  are 
lost  sight  of.  "What  mankind  is  concerned  about  is  the  revela- 
tion of  truth. 

It  is  more  than  twenty-five  years  since  the  discovery  of 
the  great  principle  that  underlies  the  practice  of  orificial  sur- 
gery. Many  isolated  facts  have  been  known,  and  the  knowl- 
edge had  been  turned  to  account  in  the  physical  betterment 
of  mankind;  but  there  had  been  no  recognition  of  the  rela- 
tivity of  these  truths;  there  had  been  no  systematic  arrange- 
ment of  the  knowledge  acquired;  there  had  not  been  the  co- 
ordination necessary  to  the  requirement  of  science.  Prior  to 
the  time  in  question  there  was  no  correlation  of  the  knowledge 
possessed  upon  the  subject.  One  fact  did  not  mean  anything 
in  particular  when  placed  in  juxtaposition  with  another  fact. 
Facts  now  known  to  be  closely  related  at  that  time  shed  no 
particular  light  upon  each  other.  Each  stood  by  itself,  and 
had  solitary  significance. 

For  instance,  the  oldest  voluntary  surgical  operation  was 
circumcision.  The  prehistoric  observer  had  learned  that  it 
was  better  to  relieve  every  male  child  of  his  foreskin,  and  it 


62  OBIFICIAL  SURGERY. 

was  done.  This  finally  was  adopted  as  a  religious  rite,  and  be- 
came eventually,  except  with  the  Jews,  Mohammedans  and  a 
few  semi-barbarous  tribes,  practically  obsolete.  It  had,  how- 
ever, no  particular  luminosity  and  suggestiveness  in  the  broad 
settlement  of  pathological  questions,  and  was  employed  only 
upon  individual  demand,  or  in  conformity  to  the  church  or- 
dinance. 

Fifty  years  ago  T.  Addis  Emmet  discovered  that  certain 
incurable  erosions  and  epithelial  vegetations  of  the  cervix 
uteri  were  due  to  the  presence  of  cicatricial  tissue,  the  result 
of  laceration  in  child  birth;  that  much  derangement  of  the 
sexual  functions  could  be  directly  chargeable  to  the  same  con- 
dition, and  that  many  neuroses  of  distant  organs  were  indirect- 
ly dependent  also  upon  this  cicatricial  cervical  plug.  The  com- 
prehension of  this  fact  was  one  of  the  most  potent  means  for 
the  quickening  of  gynecological  advancement ;  and,  next  to  the 
invention  of  the  Sims  speculum,  did  more  for  the  betterment  of 
women  than  all  that  had  preceded.  But  this  discovery,  pro- 
lific as  it  was  of  good  results,  did  not  have  any  meaning  in 
common  with  circumcision  and  the  recorded  effects  of  pre- 
putial  irritation. 

Quack  specialists  for  ages  had  plied  their  vocation  in  the 
treatment  of  piles,  but  the  work  was  regarded  as  a  dirty  busi- 
ness, and  below  the  level  of  a  learned  profession.  Finally  some 
reputable  physicians  reached  the  conclusion  that  painful  nem- 
orrhoids  demanded  attention,  and  that  it  was  legitimate  for 
professional  dignity  to  unbend  in  certain  cases  long  enough 
to  essay  relief.  But  in  every  instance  the  end  sought  was  the 
alleviation  of  local  discomfort  and  suffering.  There  was  little 
or  no  reasoning  about  the  systemic  effects  of  such  a  condition, 
and  absolutely  no  regard  paid  to  non-painful  cases — to  mor- 
bid rectal  conditions  that  gave  no  anal  discomfort.  That  rec- 
tal morbidity  had  much  to  do  in  the  provocation  of  distant  or- 
ganic disturbances  was  entertained  feebly,  if  at  all,  by  but 
few;  that  it  was  present  in  almost  all  forms  of  chronic  dis- 
ease, and  was  a  most  potent  factor,  either  in  their  causation 
or  maintenance,  was  believed  by  none.  So  far  as  kinship  be- 
tween morbid  rectum,  morbid  cervix  uteri  and  appendages,  and 


ORIFICIAL  SUEGEEY.  63 

morbid  prepuce  or  clitoris,  in  the  etilogy  of  disease,  was  con- 
cerned, there  was  no  consensus  of  opinion,  and  as  a  matter  of 
fact  no  individual  belief.  Much  evidence  had  been  taken  and 
many  facts  accumulated  along  the  different  lines,  but  there 
was  no  orderly  arrangement  of  the  knowledge  possessed,  and  it 
had  no  common  significance  when  taken  as  a  whole.  It  was  a 
heap  of  building  stones,  an  agglomeration  of  material  which 
had  not  found  its  rightful  place  in  the  walls  of  the  temple  of 
knowedge.  What  was  known,  therefore,  was  more  or  less 
chaotic  and  unsystematized. 

In  the  year  1885,  however,  it  dawned  upon  E.  H.  Pratt 
that  there  was  a  great  principle  underlying  all  these  phe- 
nomena; that  the  observations  recorded  were  of  closest  kin, 
and  when  understood  in  their  true  meaning  had  vaster  sig- 
nificance than  had  been  accorded  hitherto ;  and  that  the  dis- 
orders of  the  prepuce,  the  clitoris,  the  uterus,  the  prostate,  the 
bladder,  and  the  rectum  had  intimate  and  especial  relation- 
ship when  irritated,  not  only  with  each  other  as  the  sex  per- 
mitted, but  with  all  other  parts  of  the  body  as  well.  He  re- 
alized and  emphasized  as  none  had  done  before  that  an  irri- 
tated sympathetic  nerve-terminal  in  one  part  of  the  system 
could  be  as  much  of  a  disturber  of  the  organic  peace  as  could 
an  irritated  sympathetic  nerve-terminal  in  another  part  of  the 
system;  that  the  richest  and  most  accessible  distribution  of 
sympathetic  nerve  filaments  was  to  be  found  in  the  orifices  of 
the  body,  but  chiefly  in  the  lower  orifices,  and  that  the  welfare 
of  the  body,  the  maintenance  of  its  health  and  its  reclamation 
from  disease,  particularly  chronic  disease,  was  dependent  in 
a  most  remarkable  degree  upon  the  entire  freedom  of  these 
orifices  from  persistent  irritations.  This  bought  into  more 
prominent  discussion  than  ever  before  the  part  played  by  the 
sympathetic  nervous  system  in  the  function  called  life.  It 
made  a  sharper  contrast  between  the  anatomical  and  physio- 
logical relationship  of  the  cerebro-spinal  or  consciously  sensi- 
tive nervous  system,  and  led  us  to  the  clearer  realization  of  the 
fact  that  the  chief  office  of  the  former  was  to  preside  over  the 
volitional  functions  of  life  while  the  chief  office  of  the  latter 
was  to  preside  over  those  functions  of  the  body  that  must  be 


84  ORIFICIAL  SURGERY. 

performed  whether  the  mind  or  will  rules  or  not,  i.  e.,  the 
organic  functions.  From  this  became  more  apparent  the  fact 
that  all  pathogenesis  has  to  deal  primarily  with  the  sympa- 
thetic nervous  system;  that  all  life  manifestation  from  the 
germination  of  the  embryo  through  all  the  vicissitudes  of  ges- 
tation and  unconscious  development,  through  all  the  experi- 
ences of  the  intellectual  man,  his  wakings  and  sleepings,  his 
deliriums  and  narcoses,  till  death  supersedes  all,  are  governed 
by  the  activities  of  the  sympathetic  nervous  system;  that  the 
ultimate  residence  of  vitality — its  holiest  of  holies — is  found  in 
that  center  and  distribution  of  brain  substance  which  embraces 
and  dominates  the  ganglia  of  the  ^  sympathetic  nervous  sys- 
tem, and  that  consequently  the  study  of  pathogenesis  is  but 
the  study  of  the  morbid  manifestations  of  this  basal  expres- 
sion of  life. 

The  accentuation  of  this  groat  fact  led  to  a  deeper  and 
more  methodical  study  of  the  function  of  the  sympathetic  ner- 
vous system  in  health;  to  its  physiology  before  its  pathology. 
This  was  the  beginning  of  the  etiological  renaissance.  The 
study  of  causation  was  paramount.  The  quest  of  knowledge 
in  this  regard  was  quickened  as  never  before.  With  this  em- 
bracing thought  men  have  delved  to  greater  depths  in  the 
search  for  life-secrets,  and  deeper  insights  into  the  modus 
operandi  of  life  have  been  gained.  Knowledge  previously  at- 
tained upon  the  subject,  like  loose  sand  upon  a  vibrating  plate, 
has  fallen  into  place,  giving  shape  and  symmetry  as  well  as 
vast  indication  to  the  thought.  Men  have  felt  with  this  deeper 
view  into  life  process  a  consciousness  of  greater  nearness  to  the 
fount  of  being ;  a  sense  as  if  the  great  secret  was  within  possi- 
ble grasp,  and  that  with  yet  more  and  more  persistent  explor- 
ation it  might  be  attained.  But  while  this  north  pole  of  knowl- 
edge shall  never  be  gained  in  this  world,  the  fact  remains  that 
these  recent  years  have  brought  us  nearer  to  it  by  several  de- 
grees and  that  the  knowledge  thus  acquired  enables  us  to 
ameliorate  to  a  greater  extent  than  ever  before  the  ills  to  which 
mankind  is  subject. 

Coming  now  from  the  abstract  to  the  concrete,  let  us  con- 
sider this  subject  somewhat  more  in  detail ;  let  us  understand 


OEIFICIAL  SUBGEBY.  65 

more  clearly  what  it  all  means.  I  have  said  above  that  the 
primary  fixation  and  establishment  of  the  human  soul  in  visible 
matter  is  evidenced  in  the  ultimate  by  the  manifestations  of 
the  sympathetic  system  of  nerves;  that  as  far  back  in  organi- 
zation as  we  are  permitted,  in  the  individual  case,  to  go,  i.e.,  to 
the  time  of  the  coalescence  of  the  two  germs  in  the  matrix,  the 
life  expression  is  served  and  voiced  by  this  medium.  I  will 
say  further  that  observation  and  inference  prove  the  same  to 
be  true  of  the  life  manifestation  in  all  the  stages  and  grada- 
tions of  animal  evolution  back  even  to  the  amoeboid  protoplasm 
of  the  great  primal  ooze,  or  to  the  period  of  impossible  differ- 
entiation between  sensitive  animal  and  sensitive  plant;  that 
from  that  ancient  creation-day  through  all  animate  existence, 
including  the  human  family  and  the  units  thereof,  to  the  final 
day  of  individual  death,  the  sympathetic  nervous  system,  sim- 
ple or  complex,  has  subserved  the  ends  of  existence  and  been 
its  conservator. 

Nothing  can  go  further  toward  the  establishment  of  faith 
in  an  All-Wise  Father  and  Universal  Providence  than  the  sweep 
of  this  mighty  thought.  When  one  but  faintly  realizes  the  in- 
telligent provision  and  protection  that  has  been  exercised  over 
all  the  feeble  folk  of  the  world  through  all  the  vista  of  time, 
that  while  millions  of  the  different  families  in  the  chain  of  de- 
velopment never  awoke  to  consciousness  during  the  period  of 
their  earthly  lives  but  were  yet  endowed  with  an  organic  in- 
telligence that  continued  to  perform  the  life  functions  and 
evolve  to  higher  conditions;  when  one  senses  the  fact  that  in 
the  specific  instance  of  the  man's  own  life,  through  all  that 
dark  night  of  existence  in  utero  and  babbling  childhood,  pre- 
ceding his  awakening  to  the  sense  of  existence,  and  through  all 
subsequent  periods  of  darkness  occasioned  by  natural  sleep  or 
morbid  obscurations  from  whatever  cause — also  during  his 
waking  but  careless  and  forgetful  moments  as  well — his  faith- 
ful servant  the  sympathetic  nervous  system  has  been  attending 
strictly  to  its  assigned  task  of  life-supervision,  I  say  when  one 
realizes  all  this,  he  can  but  feel  that  he  has  been  kept  as  in  the 
hollow  of  a  Mighty  Hand,  that  Life  from  God  preceded  all  or- 
ganization and  that  man  is  but  a  passenger  on  the  great  train 


66  OBIPICIAL  SURGERY. 

of  being.  But  while  the  human  mind  is  thus  brought  into  a 
realization  of  this  fact  of  subserviency  to  the  "power  not  our- 
selves" that  works  for  the  Tightness  of  our  physical  lives,  it 
is  led  still  further  into  the  contemplation  of  this  mechanism 
that  God  uses  primarily  to  accomplish  human  life. 

The  great  study  of  the  present  and  all  future  time  must  be 
the  study  of  this  connecting  link,  or  chain  of  links  between 
the  soul  and  the  body,  or  mind  and  matter.  This  is  the  great 
interrogation  that  shall  fascinate  men  while  time  lasts  but  the 
ultimate  answer  to  which  shall  ever  recede  before  them  as  one 
acquisition  of  knowledge  after  another  is  made.  Certainly  no 
greater  question  can  exercise  the  minds  of  men  than  how  they 
may  touch  and  influence  the  generator  and  liberator  of  life- 
force  and  thus  be  enabled  to  work  together  with  this  great  and 
silent  power  in  the  banishment  of  physical  ills. 

Having  realized  that  the  life-force  is  resident  in  the  depths 
of  the  nervous  system  and  that  the  very  citadel  and  reservoir 
of  this  force  is  that  portion  of  it  known  as  the  sympathetic, 
observation  must  center  itself  upon  the  phenomena  of  the  sym- 
pathetic. How,  then,  may  we  reach  and  impress  the  sympa- 
thetic ? 

The  chapter  concerning  the  "reflexes"  has  now  grown  to 
be  a  very  long  one  and  it  would  be  tautological  for  me  to  go 
into  any  lengthy  dissertation  upon  them.  It  will  be  enough 
for  me  to  cite  them  as  instances  of  sympathetc  irritation ;  and 
to  remind  you  that  all  nerves  are  made  to  report  contact,  es- 
pecially inimical  contact. 

Sensation,  whether  conscious  or  not,  always  comes  from 
the  periphery,  the  terminals  of  distribution.  So  far  as  the  cere- 
bro-spinal,  or  the  markedly  sensitive  nerves  are  concerned  it 
must  come  from  contact  surfaces,  chiefly  from  the  integumen- 
tary portions  of  the  body  and  from  regions  of  special  sense. 
There  is  a  notable  difference  of  sensitivity  even  among  nerves 
of  this  class  dependent  upon  their  use  and  education,  the 
nerves  of  the  index  finger  for  instance  attaining  a  proficiency 
in  intelligence  almost  beyond  the  boundaries  of  belief.  So  far 
as  the  sympathetic  or  markedly  insensitive  nerves  are  con- 
cerned impressions  must  come  also  from  their  peripheral  dis- 


OEIFICIAL  SUEGBBY.  67 

tributions.  Being  the  nerves  of  the  organs  of  the  body  they 
are  restricted  in  their  external  expansions  to  the  orifices  of  the 
body.  The  periphery  of  distribution  of  the  sympathetic  nerve- 
terminals  has  been  found  to  be  almost  wholly  in  the  body 's  ori- 
fices. Their  language,  however,  is  not  primarily,  pain  to  the 
ego ;  but  discord  among  the  life  harmonies.  It  requires  trans- 
lation into  terms  of  sensorial  understanding  before  the  inter- 
pretation is  complete.  One  must  become  a  reader  of  the  facies 
sympathetica  if  he  would  know  the  significance  of  the  mes- 
sage conveyed;  he  must  be  trained  to  look  through  symptoms 
to  causation.  The  patient  who  does  not  bear  ample  facial  evi- 
dence of  his  illness;  who  does  not  get  credit  from  his  fellows 
for  his  bad  feelings ;  who  has  given  expression  in  his  long  con- 
tinued complaints  to  a  variety  of  neuralgic  or  secondary  man- 
ifestations in  different  localities;  who  recognizes  that  his  phy- 
sical abilities  have  a  short  limit  and  that  he  can  do  no  more 
than  so  much  without  inducing  prostration  or  some  familiar 
"spell,"  and  who  shows  in  measurable  ways  a  progressive 
waste  of  that  substance  which  we  call  vitality — that  patient  I 
say  bears  the  insignia  of  an  embarrassed  sympathetic  and  is 
under  orificial  indictment. 

So  far  as  we  can  see  there  is  a  notable  difference  of  im- 
pressionability also  among  sympathetic  nerves — the  nerves  of 
one  orifice  giving  more  marked  expression  in  certain  ways  than 
another. 

Rhinologists  and  laryngologists  have  been  led  to  believe 
that  the  chief  and  most  important  sources  of  reflex  irritability 
are  to  be  found  in  the  nose  and  throat;  while  their  antipodal 
co-workers,  the  pelvic  specialists,  are  impressed  with  the  belief 
that  the  greatest  reactions  of  the  sympathetic  are  resultant 
from  the  irritations  of  the  urethra,  the  uterus,  and  the  rectum 
— particularly  the  rectum — and  the  extensions  and  relations 
of  these  respective  tubes.  But  this  division  of  opinion  is  but 
superficial,  and  is  dependent  upon  the  restriction  of  vision 
to  a  given  locality.  Taken  together  the  observations  of  all 
orificial  co-workers  are  complimentary,  and  round  to  the  full 
the  truth  that  the  nerve-wastes  due  to  persistent  irritations 


68  OBIFICIAL  SURGERY. 

of  one  or  more  of  the  body's  orifices  have  largely  to  do  with 
the  impairment  of  vitality  and  are  the  origin  and  dependency 
of  most  cases  of  pathogenesis. 

The  evidence  is  cumulative  that  all  disease  manifestation 
is  but  proof  of  impairment  of  vitality ;  that  when  the  Leyden- 
jar  of  life  is  full  and  the  electric  discharge — if  you  may  so 
call  it — vigorous  and  repellant,  there  can  be  no  morbidity; 
and  that  the  measure  of  health  is  correlative  always  with  the 
volume  of  vitality.  Search  far  and  wide  and  you  will  find 
that  it  is  only  the  vulnerable  who  succumb;  that  it  is  only 
the  susceptible  who  are  affected;  that  those  fortified  by  their 
due  allotment  of  reserve  force  go  through  unharmed,  and  that 
never  can  regainment  of  lost  life  or  health  be  made  until  the 
waste  of  vital  force  be  stopped  and  be  reversed  into  an  in- 
crement. This  is  especially  true  of  chronic  diseases  and  has 
relevancy  also  to  zymotic  diseases  and  many  diseases  of  the 
accidental  type.  Convalescence  implies  increment  of  vital 
force ;  it  implies  the  cessation  of  inimical  influences ;  it  implies 
peace  and  harmony  in  the  sympathetc  nervous  system. 

Men  may  sneer  at  and  speak  derogatively  of  your  propo- 
sition when  you  explain  the  common  causation  of  extensive 
and  apparently  non-related  diseases,  and  when  you  insist  upon 
the  discovery  of  what  to  them  appears  to  be  a  wholly  inade- 
quate irritation;  but  this  is  evidence  only  of  their  slow  rate  of 
travel;  it  is  proof  only  that  they  are  still  copyists  of  obselete 
formulas.  They  have  not  learned  the  lesson  of  Sinai,  that  the 
Lord  was  not  in  the  thunder  and  tempest,  but  in  the  still  small 
voice,  and  that  the  greatest  physical  revulsions  witnessed  by 
pathologists  may  be  due  to  a  seemingly  inconsequential  dis- 
turber of  the  organic  peace. 

Up-to-date  oculists  are  no  longer  doubting  that  the  strum- 
ous  diseases  with  which  they  have  to  contend  are  due  to  some 
causation  of  vital  poverty,  and  that  their  results,  even  to  the 
rectification  of  accommodative  and  other  nerve  difficulties, 
are  dependent  upon  the  restoration  of  that  lost  vitality. 
Thoracic  specialists  are  realizing  that  the  asthma  and  incipient 
phthisis  encountered  by  them  has  been  induced,  and  may  be 


OBIFICIAL  SURGEEY.  6d 

fostered  by  some  hypertrophy  of  nose  or  throat,  by  some  dist- 
ant pelvic  irritation,  by  some  reducer  of  vitality  in  some  near 
or  remote  part  of  the  economy.  Dermatologists  are  learning 
that  their  herculean  task  of  diagnosis  and  reconciliation  of 
variant  nomenclatures  is  superficial,  and  unsatisfactory  if  the 
deeper  search  for  causation  is  not  prosecuted  to  the  ultimate. 
They  will  learn,  if  they  have  not,  that  the  exhibitions  upon 
the  plane  of  the  integument  are,  the  most  of  them,  but  reflexes 
and  that  the  most  brilliant  cures  cannot  be  made  till  all 
sympathetic  disturbances  have  been  quieted.  They  will  rec- 
ognize that  even  parasitic  dermatoses  are  dependent  upon  the 
ease  with  which  a  nidus  is  made,  and  that  this  too  is  largely 
a  question  of  susceptibility.  Alienists  and  neurologists  are 
awakening  to  the  fact  that  the  sweet  bells  of  the  mind  never 
go  jangling  and  out  of  tune  while  harmony  prevails  in  that 
substructure  of  the  economy  upon  which  all  life  interpretation 
is  posited;  that  such  a  thing  as  insanity  without  an  embar- 
rassed sympathetic  is  rare,  and  that  if  the  history  of  each 
case  had  been  carefully  written,  it  would  show  that  the  in- 
ception of  the  mental  alienation  of  most  of  the  unfortunate 
persons  incarcerated  in  the  mad-houses  of  the  world  was 
made  through  the  devastating  influences  of  orificial  irritation. 
Cases  of  cranial  depression  aside,  and  the  lunatic  without 
morbid  rectum  or  morbid  genitals,  is  an  anomaly.  This  is 
but  another  way  of  saying  that  the  most  of  the  mad  people 
of  the  world  ought  to  be,  and  can  be,  pacified  and  returned 
to  their  avenues  of  useful  occupation  in  an  incredibly  short 
space  of  time. 

Specialists  of  all  sorts,  in  short,  are  finding  out  that  they 
are  addressing  but  parts  of  a  great  whole;  that  the  part  of 
the  body  which  is  claiming  their  especial  attention  is  con- 
nected most  intimately  with  the  central  organism,  and  that 
it  is  dependent  for  its  welfare  upon  the  welfare  and  normal 
function  of  that  central.  Every  specialist  deserving  the  name 
has  learned  that  he  must  be  a  generalist  also  if  he  would 
determine  with  any  degree  of  credibility  the  peculiar  sig- 
nificance of  local  phenomena  and  to  what  extent  the  local 


70  ORIFICIAL  SURGERY. 

is  controlled  or  influenced  by  the  general.  For  this  reason 
it  is  that  the  recent  discoveries  touching  the  universal  in- 
fluences of  sympathetic  irritation  are  germane  to  all  remedial 
effort;  that  no  specialist  can  attain  reasonable  success  without 
the  restoration  of  the  equilibrium  of  the  sympathetic  nervous 
system,  and  that  this  can  not  be  done  till  all  orificial  irrita- 
tion has  been  abated. 

Organic  diseases  there  are.  Yes,  but  every  organic  disease 
is  a  thing  of  slow  development;  it  is  an  index  of  crippled 
vitality  and  existed  for  a  longer  or  shorter  time  as  a  func- 
tional. It  did  not  come  full-formed  without  a  moment 's  notice. 
The  sympathetic  in  every  instance  fought  a  good  fight,  and, 
when  the  odds  were  finally  too  much  for  it,  the  effects  of 
the  discord  became  crystallized  into  organic  defect.  The 
best  way  to  cure  organic  diseases  is  to  prevent  them ;  and  the 
best  way  to  prevent  them  is  to  relieve  the  sympathetic  nerv- 
ous system  of  all  persistent  irritation  and  nagging;  and  the 
best  way  to  prevent  irritation  and  nagging,  nerve  waste  and 
vital  loss,  is  to  attend  to  the  orifices  of  the  body. 

So  long  as  poverty  is  the  characteristic  of  the  life  capital, 
so  long  shall  the  individual  be  haunted  by  a  thousand  physical 
fears ;  so  long  shall  he  give  expression  to  manifold  and  widely 
variant  inabilities;  so  long  shall  he  be  the  unfortunate  candi 
date  for  ultimate  organic  disease. 

The  most  appropriate  time  to  make  a  life-examination  is 
not  when  some  corporation  is  willing  to  make  a  money  wager 
upon  the  life  in  question;  but  primarily  when  the  life  is  first 
ushered  into  the  world.  If  close  inspection  were  then  made, 
much  subsequent  misfortune  would  be  averted.  If  the  orifices 
of  the  new-born  were  known  to  be  normal;  particularly  if 
every  prepuce  or  clitoris  were  proven  to  be  free  from  ad- 
hesions, and  every  imprisoned  cake  of  smegma  behind  such 
adhesions  were  liberated,  how  much  outcry  might  not  be  pre- 
vented— how  many  cases  of  convulsions  and  nutritional 
diseases  might  not  be  thus  hedged  against?  If  it  were  a  law 
that  in  the  progress  of  life  an  all-over  examination  of  the 
body  should  be  made  by  an  expert  at  stated  intervals,  say 


ORIFICIAL  SURGERY.  71 

every  three  or  five  years,  whether  symptoms  were  recognized 
or  not,  it  would  be  a  great  advancement.  And  if,  in  addition, 
every  individual  could  be  possessed  with  the  knowledge  of 
the  necessity  for  the  immediate  removal  of  the  irritant,  how- 
ever trivial,  and  a  willingness  to  follow  the  indication  to 
whatever  extent,  how  much  functional  disease  might  not  be 
evaded,  and  how,  almost  wholly,  might  not  organic  diseases 
be  ruled  out  ?  This  is  all  the  more  necessary  since  it  is  known 
that  sympathetic  irritations  can  go  on  without  the  recogni 
tion  of  the  patient ;  since  the  fact  has  been  revealed  that  the 
sympathetic  nerves  have  conscious  sensation  to  a  very  feeble 
extent,  if  at  all,  and  that  they  usually  reflect  their  disturb- 
ances for  the  most  part  to  distant  nerves  and  organs  for 
report,  and  since  it  is  indisputably  proven  that  all  disease  is 
preceded  by  progressive  waste  of  vital  force. 

The  advancement  in  this  knowledge  of  the  causation  of 
disease  and  the  great  strides  made  through  its  exercise  in 
the  amelioration  and  banishment  of  human  ills,  is  the  great- 
est contribution  to  medical  science  during  the  nineteenth 
century.  Whatever  in  the  future  may  be  the  modification  of 
the  technique  of  this  or  that  orifieial  surgical  procedure,  the 
great  truths  of  the  orifieial  philosophy  will  hold  their  places 
upon  the  scroll  of  science  and  be  amplified  more  and  more 
into  fuller  meaning  as  the  perfect  day  of  knowledge  shall 
come. 

But  while  it  is  true  on  the  one  hand  that  orifieial  exami- 
nation and  restoration  is  a  prerequisite  to  cure  in  almost 
every  instance  of  physical  malady,  and  that  every  physician, 
whether  general  or  special,  must  avail  himself  of  the  assist- 
ance afforded  by  the  teaching  and  practice  of  orifieial  surgery 
if  he  would  effect  the  speediest  and  most  permanent  cure  of 
his  cases,  especially  of  all  chronic  cases,  it  is  no  less  true  on 
the  other  hand  that  the  knowledge  of  the  physiology  and 
pathology  of  the  orifices,  is  expert  knowledge  of  the  highest 
order,  and  that  tyros,  however  well  skilled  in  other  branches 
of  healing,  are  in  no  sense  qualified  to  put  into  practice  its 
major  operations.  It  requires  the  finest  discrimination  often 


72  ORIFICIAL  SURGERY. 

to  make  an  orificial  diagnosis,  and  no  branch  of  surgical 
practice  demands  to  a  greater  degree  an  established  technique. 
Inexperience  has  been  the  basis  of  most  of  the  deplorable 
results  in  all  branches  of  surgery.  Until  methods  have  been 
perfected  through  trial,  much  failure  and  disappointment 
must  be  realized.  The  history  of  surgery  abundantly  attests 
the  accuracy  of  this  statement.  No  medical  man,  therefore, 
and  no  surgeon  even,  is  qualified  to  practice  orificial  surgery 
until  he  has  acquired  the  technique  especially  called  for  and 
demanded  by  the  surgery  pertaining  to  the  sphincter  muscles. 
While  all  can  detect  the  more  patent  forms  of  preputial  and 
rectal  irritations  and  rectify  them  to  some  extent,  none  but 
an  expert  should  essay  the  major  orificial  procedures. 

Let  no  one  suppose  that  orificial  surgery  is  trivial  surgery 
and  that  any  first-course  student  is  capable  of  performing  it. 
I  affirm  that  no  surgeon  requires  higher  skill  than  the  orificial 
surgeon,  and  that  the  operations  which  he  may  be  called  upon 
to  perform  take  rank  in  their  difficulties  and  dangers  with 
coeliotomy  or  any  capital  operation.  When  these  truths  shall 
have  been  realized  to  the  full,  there  will  be  fewer  practi- 
tioners of  orificial  surgery  and  a  far  higher  grade  of  orificial 
work.  When  that  day  shall  have  arrived  much  of  the  criti- 
cism now  in  some  measure  just,  will  have  disappeared,  and 
orificial  surgery  stripped  of  its  burdens  and  embarrassments 
will  be  fully  equipped  for  its  usefulness,  and  will  continue 
to  bless  mankind  while  that  kind  continues  to  exist. 


CHAPTER  VII. 

A  SYNOPSIS  OP  ORIFICIAL  SURGERY  AND  WHAT  IT 
HAS  ACHIEVED,  WITH  A  REPORT  OF  CASES. 


LIBBIE   HAMILTON   MUNCIE,   M.   D.,   PH.   M. 


When  an  earnest  advocate  of  any  system  endeavors  to 
make  plain  its  virtues,  he  is  an  exception  to  the  rule,  if  he 
escapes  the  criticism  of  being  incapable  of  seeing  any  good 
outside  of  his  specialty,  and  of  making  claims  for  that  sys- 


OEIFICIAL  SUKGBRY.  73 

tern  far  beyond  its  true  worth.  So  much  does  each  one  live 
within  himself  that,  as  deplorable  as  it  may  be,  this  criticism 
is  too  often  just.  There  are  many  useful  measures  in  this 
age  of  science  for  the  relief  of  the  sick,  but  all  are  applied 
for  the  one  great  purpose  of  equalizing  capillary  circulation. 
How  to  best  reach  that  neurotic  influence  which  controls  cir- 
culation is  the  great  aim,  and  is  perfectly  or  imperfectly 
accomplished  in  many  ways.  All  must  act  through  this  chan- 
nel, and  every  panacea  that  ever  has  or  ever  will  exist  has  its 
place,  and  will  be  so  acknowledged  by  the  true  physician.  The 
orificialist  is  forced  to  believe  that  the  majority  of  chronic 
diseases  have  their  origin  in  pathological  conditions  at  the 
lower  openings  of  the  body,  because  he  has  seen  the  most 
excruciating  chronic  suffering  promptly  relieved  and  perm- 
anently cured  by  the  removal  of  these  lesions;  he,  therefore, 
must  conclude  that  these  methods  stand  first  in  rank,  and 
although  the  philosophy  is  correct,  judgment  and  technique 
may  be  faulty.  Also,  there  will  be  found  cases  which  have 
passed  over  the  boundary  line  where  reactive  power  is  so  far 
destroyed  that  only  death  itself  can  emancipate  them  from 
their  suffering.  This  fact  should  urge  the  surgeon  to  a  more 
expert  judgment  in  selecting  his  cases.  It  must  be  remem- 
bered that  the  cases  presented  to  the  orificialist  are  usually 
those  which  are  nearing  this  boundary  line,  and  that  the 
orificial  work  is  not  the  agent  which  cures  the  patient,  but 
that  which  removes  the  barrier  from  the  way,  thus  equalizing 
circulation  and  enabling  nature  to  recall  her  discordant  forces 
into  harmonious  action. 

This  process  is  often  slow,  because  nature  seems  to  make 
no  account  of  time;  therefore,  it  is  not  uncommon  to  meet 
with  those  cases  where  recovery  is  tardy,  but  nevertheless 
sure. 

There  is  a  disposition  in  all  the  walks  of  life,  with  a 
large  proportion  of  individuals,  to  investigate  no  system, 
however  well  founded,  until  it  has  won  by  its  true  merit  a 
large  following.  There  are  others  who,  like  Peter  of  old,  rush 
eagerly  in  advance  of  his  incredulous  companions;  thus  he 


74  OBIPICIAL  SURGERY. 

more  quickly  receives  the  good,  and  rejects  the  bad.  His 
more  conservative  brother  sooner  or  later  reaps  the  benefit 
from  his  investigation,  though  he  resists  most  bitterly  for  a 
season,  thereby  not  only  hampering  the  progress  of  his  en- 
thusiastic friend,  but  belittling  the  influence  that  he  himself 
might  otherwise  have  enjoyed.  The  time  has  arrived  when 
tivery  honest,  though  most  conservative,  physician  and  surgeon, 
must  acknowledge  that  the  so-called  orificial  surgery  has 
achieved  great  results,  since  there  are  now  scattered  through- 
out the  United  States  many  most  successful  private  sanatori- 
ums  which  are  an  outgrowth  from  the  practical  application  of 
orificial  methods.  The  equipment  of  these  private  hospitals 
and  the  prosperity  they  enjoy  is  second  to  none;  therefore, 
it  may  be  said  that  orificial  surgery  has  achieved  the  erec- 
tion of  institutions.  It  has  established  chairs  in  many  medical 
colleges  in  this  country.  It  has  enlarged  the  field  of  useful- 
ness for  every  physician  who  has  practiced  its  teachings; 
and  better  than  all  else,  it  has  relieved  the  sufferings  of  thous- 
ands who  have  turned  to  its  methods  as  a  last  resort. 

It  has  been  demonstrated  by  a  large  number  of  the 
medical  profession,  that  when  dealing  with  the  lower  orifices 
of  the  body,  because  of  the  rich  commingling  of  the  branches 
from  the  pudic  nerve,  and  those  from  the  hypogastric  plexus, 
there  is  aroused  that  neurotic  influence  which  flushes  the 
capillaries  thus  controlling  nutrition,  which  is  essential  to 
the  vitality  of  every  part.  The  human  body  is  inflicted  with 
all  forms  of  pathological  lesions  at  the  terminal  portion  of 
the  sympathetic  system,  from  the  preputial  adhesions  and 
rectal  papillae,  to  the  various  large  tumors  of  the  pelvic 
cavity.  It  is  not  only  a  theory,  but  it  has  been  thoroughly 
proven,  from  practical  experience  in  thousands  of  cases,  that 
even  the  smallest  of  these  pathological  irritations  will  in 
many  cases,  so  hamper  the  activities  of  the  sympathetic  nerv- 
ous system,  as  to  cause,  at  some  remote  point,  the  most  pro- 
found functional  disturbances;  we,  therefore,  find  all  forms 
of  chronic  diseases,  from  neurasthenia  to  insanity,  from  hyper- 
trophy to  atrophy,  coming  within  the  scope  of  its  practice. 


ORIFICIAL  SURGERY.  75 

Orificial  surgery,  then,  is  that  agent  which  seeks  to  remove 
all  points  of  irritation  from  the  accessible  portion  of  the 
sympathetic  terminals,  whereby  she  is  enabled  to  perform 
all  her  functions,  unhampered  from  her  regulating  power  over 
the  greater  involuntary  activities  of  existence,  to  the  most 
remote  infinitesimal  and  homogeneous  functions  of  life.  A 
careful  study  of  the  physiology  and  anatomy  of  the  great 
sympathetic  system,  in  combination  with  the  voluntary  com- 
manding forces,  or  the  cerebro-spinal,  enables  one  to  under- 
stand easily  why  any  chronic  disease  is  but  an  evidence  of 
enervated  nerve  force  or  a  lessening  of  the  natural  resistance 
power  against  its  ravages.  It  is  said  that  we  are  frequently 
confronted  with  organic  diseases,  yet  all  these  organic  dis- 
eases, barring  the  congenital,  are  preceded  by  functional 
disturbances  which  are  actuated  by  nervous  influences.  Nerv- 
ous influences  outside  of  mental  shock  and  worry  are  usually 
due  to  pathological  conditions  at  the  orifices;  therefore,  there 
cannot  be  a  chronic  sufferer  produced,  who  upon  experienced 
investigation  will  not  present  pathology  at  the  lower  open- 
ings of  the  body.  The  irritation  may  be  so  slight  as  to  be 
ignored  by  those  physicians  who  have  not  learned  that  a 
tightened  frenum,  or  a  slight  preputial  adhesion,  or  a  rectal 
papilla,  will  produce  upon  certain  sensitive  individuals  a  more 
profound  systemic  disturbance  than  in  another  case  may  be 
produced  by  pathology  so  pronounced  as  to  be  easily  recog- 
nized by  any  first-year  medical  student.  Inasmuch,  then,  as 
the  repair  of  a  lacerated  cervix,  and  other  orificial  pathology, 
so  often  results  in  the  alleviation  and  cure  of  many  reflex 
neuroses,  does  it  not  speak  relief  for  millions  of  chronic  suf- 
ferers heretofore  beyond  help?  If  the  lower  orifices  of  the 
body  could  be  kept  free  from  all  pathological  conditions  from 
infancy  to  old  age,  then  the  surgical  profession  would  be  re- 
lieved of  the  painful  necessity  of  performing  capital  operations 
except  in  cases  of  accident  or  inherited  tendencies,  and  the 
latter  would  be  long  deferred,  instead  of  siezing  the  victim 
at  the  first  unfavorable  circumstances  of  life. 


76  ORIFICIAL  SURGERY. 

It  should  be  borne  in  mind  that  physical  conditions  are 
not  unlike  moral  states.  The  nervous  system  takes  upon 
itself  habits  which  it  is  not  easy  to  immediately  overcome; 
therefore,  in  the  long-continued  habits  of  chronic  sufferers, 
there  will  often  be  found  not  only  the  primary  lesion  to  over- 
come, but  other  effects  which  in  turn  become  causes,  and  so 
on  through  an  almost  endless  chain,  which  may  be  illustrated 
in  the  following  lines: 

"Fleas  have  fleas  on  'em  that  bite  'em; 
These  fleas  have  fleas  ad  infinitum." 

It  will  be  observed  that  agencies  which  before  the  surgi- 
cal work  was  performed  were  absolutely  inert  will  afterward 
become  effective  should  other  agents  be  needed. 

In  dealing  with  these  chronic  diseases,  a  patient  should 
be  under  observation  for  at  least  one  year  after  the  operation, 
and  during  that  year  it  may  be  advisable  to  anesthetize  him 
once  or  twice  for  the  removal  of  any  smaller  pathology  which 
it  may  have  been  unadvisable  to  remove  at  the  time  of  the 
major  operation;  although  in  most  cases,  where  immediate 
operation  is  not  imperative  (as  in  septicemia  or  pyemia),  it 
is  better  to  perform  a  preparatory  operation,  consisting  of  a 
clearing  of  all  pathological  conditions  from  the  external  geni- 
tals and  rectum. 

This  work  will  equalize  the  circulation,  thereby  strength- 
ening the  weak,  fluttering  heart,  often  bringing  it  down  from 
one  hundred  beats  to  seventy  for  each  consecutive  minute. 
From  one  to  two  weeks  after  this  minor  surgery,  there  may 
be  performed  the  major  operation,  with  little  shock  to  the 
patient,  and  a  happy  lessening  of  anxiety  to  the  surgeon.  Be- 
cause of  most  astounding  and  gratifying  results  in  many 
cases,  one  naturally  becomes  impatient  over  the  slow  recov- 
eries in  other  cases.  These,  however,  frequently  present  the 
most  satisfactory  results  in  the  long  run.  It  is  not  uncommon 
to  have  patients  who  were  operated  upon  three  or  four  years 
ago  make  the  statement  that  they  feel  that  they  are  still 
gaining  strength  from  month  to  month,  and  year  to  year.  For 
that  class  which  requires  careful  accessory  treatment  for  some 


ORIFICIAL  SUEGERY.  77 

months  following  an  operation,  there  are  many  measures  which 
will  prove  of  benefit;  such  as  electricity,  massage,  baths,  ice- 
packs, drugs,  etc.  These  agencies,  however,  in  many  cases 
are  of  less  importance  than  is  the  attention  to  the  maintaining 
of  the  pelvic  organs  in  a  normal  position.  Too  much  cannot 
be  said  in  this  direction.  These  results  may  often  be  accom- 
plished after  a  proper  all-around  operation  has  been  performed 
where  it  was  out  of  the  question  before,  without  causing  ex- 
cruciating pain,  and  small  fibroids  and  complications  of  the 
ovaries  and  tubes  will  often  disappear. 

As  to  the  use  of  pessaries,  they  have  their  virtues.  It  is 
often  important  that  they  be  used  in  the  proper  cases,  and 
for  the  proper  length  of  time,  and  that  they  are  perfectly 
fitted  to  the  case  in  question.  "When  judiciously  used,  they 
hasten  the  patient's  restoration  to  health,  making  it  possible 
for  her  to  enjoy  activities  with  the  healthy  from  which  she 
would  otherwise  be  deprived. 

The  occasional  dilatation  with  the  graded  sound,  of  the 
internal  os,  followed  by  the  use  of  the  intra-uterine  stem 
pessary,  will  give  great  relief  in  many  cases.  Although  un- 
warrantable injury  has  often  been  observed  from  the  injudi- 
cious use  of  pessaries,  they  should  not  be  cast  aside  as  valueless, 
for  in  proper  hands  they  hold  a  very  important  place  in 
gynecological  treatment. 

The  Thomas  intra-uterine  electrode  stem  pessary  deserves 
special  mention.  They  come  in  several  sizes,  and  are  just 
what  their  name  indicates.  They  are  especially  useful  in 
those  cases  presenting  atonic  uterine  walls  with  flexion,  and 
in  the  undeveloped  states.  The  glass  stems  are  considered 
better  adapted  to  the  hyperesthetic  cases,  where  the  patient 
may  have  to  be  kept  under  the  influence  of  an  anodyne  for 
perhaps  a  day,  until  the  uterus  ceases  to  rebel;  this  it  may 
not  do  at  the  first  attempt,  when  it  becomes  advisable  to 
allow  the  patient  to  wait  a  week  before  replacing.  It  must 
be  asserted,  that  no  physician  should  make  use  of  stem  pes- 
saries until  he  has  become  sufficiently  experienced  in  pelvic 


78  ORIFICIAL  SURGERY. 

examinations  to  diagnose  with  some  degree  of  certainty  con- 
ditions above  the  cul-de-sac. 

The  most  telling  presentation  of  what  the  methods  under 
consideration  have  achieved  in  the  relief  of  chronic  condi- 
tions can  best  be  given  in  a  report  of  cases.  We  will  therefore 
select  from  the  clinic  book  only  those  cases  which  had  re- 
ceived professional  attention  from  physicians  in  high  standing, 
and  had  turned  to  these  methods  when  all  else  had  failed. 
Those  persons  only  will  be  mentioned  with  whom  we  are  now 
in  direct  communication,  enabling  us  to  speak  positively  of 
their  present  condition.  "While  all  cases  have  not  been  so 
satisfactory  as  these  which  shall  be  given,  it  can  honestly 
be  said  that  the  disappointments,  or  failures  as  some  would 
term  them,  have  been  so  few  that  were  they  mentioned  here, 
there  would  be  a  very  small  space  occupied. 

Case  1. — One  year  ago  there  came  to  our  care  a  man 
who  had  been  insane  for  four  years.  His  history  was  as 
follows:  Mr.  C.,  age  48,  married.  A  man  of  excellent  habits 
and  social  standing,  having  for  twenty  years  occupied  a 
very  responsible  business  position.  In  disposition  he  had 
always  been  one  to  see  the  bright,  and  withal  the  ridiculous 
side  of  circumstances,  and  had  enjoyed  exemption  from  dis- 
ease during  his  life,  save  for  occasional  attacks  of  indigestion. 

In  1892  he  was  seized  with  la  grippe  of  a  very  severe 
type,  which  left  him  a  raving  maniac.  In  about  six  months 
he  became  more  quiet.  After  many  consultations  with  expert 
mental  specialists,  the  case  was  abandoned  as  hopeless.  It 
was  in  April,  1896,  the  writer  first  saw  the  patient,  who  was 
in  the  most  profund  distress  because  he  "had  committed  the 
unpardonable  gin."  He  conversed  with  great  reluctance, 
showing  an  inability  to  produce  the  word  expressing  his 
meaning,  whereupon  he  would  throw  up  his  hands  in  an  atti- 
tude of  despair,  with  a  broken  ejaculation  of  hopelessness. 
The  next  day,  when  anesthetized,  we  discovered  a  pale  Brians 
penis  with  an  irritable  pouting  urethral  orifice,  and  a  very 
tight  frenum.  Upon  dilatation  of  the  rectum  (which  lay  par- 
tially open  before  dilating),  there  appeared  a  zone  of  grisley 


OBIFICIAL  SUBGERY.  79 

papillae,  ranging  in  size  from  one  eighth  of  an  inch  to  an 
inch  and  a  half  long,  pointing  upward  and  overhanging  a 
mass  of  old  hemorrhoidal  tissue,  the  blood-clots  having  under- 
gone hardening  and  partial  organization.  The  operation 
consisted  in  the  passing  of  graded  steel  urethral  sounds  to 
the  extent  of  perfect  relaxation,  clipping  the  frenum,  and  a 
thorough  slit-operation  upon  the  rectum,  bringing  the  slits 
well  outward  to  the  integument  and  inward  above  the  internal 
sphincter,  leaving  but  a  few  almost  hair-lines  of  mucous 
membrane  to  proliferate.  After  completing  the  operation  a 
good-sized  rectal  plug,  wrapped  in  the  fluid  extract  of  ham- 
amelis,  hypericum  and  calendula,  was  inserted  in  the  rectum 
and  left  there  for  about  six  hours.  The  patient  meantime 
was  kept  quiet  by  morphia.  The  next  morning  he  smiled  and 
said  "the  clouds  are  passing  away."  The  wife  and  daughter 
declared  that  he  had  not  appeared  so  much  like  himself  in  all 
the  four  years,  for  during  that  time  a  smile  had  not  once 
marked  his  countenance.  Every  day  the  improvement  be- 
came more  marked,  until  five  weeks  later  he  was  returned 
to  his  home  "like  his  old  self,"  with  the  exception  of  slowness 
of  speech,  which,  however,  was  entirely  overcome  in  three 
weeks  more.  He  soon  assumed  a  responsible  position  in  the 
Auditor's  office,  giving  perfect  satisfaction.  He  remains  a 
perfectly  cured  man,  even  though  he  has  had  many  difficulties 
to  encounter,  through  illness  in  his  family. 

Case  2. — Mrs.  P.,  age  58,  had  been  suffering  with  melan- 
cholia for  eight  years,  during  which  time  there  had  never 
been  a  perfectly  lucid  moment.  She  had  been  under  treat- 
ment in  three  of  the  best  institutions  in  the  East,  and  at  times 
in  her  own  home  under  the  best  neurologists  of  her  city,  but 
to  no  avail.  She  was  presented  to  us  in  the  fall  of  1894.  Her 
condition  was  then  rapidly  passing  on  to  that  of  dementia. 
Her  husband  stated  that  he  had  spent  a  fortune  seeking  her 
restoration,  and  he  now  brought  her  here  as  the  last  resort, 
inasmuch  as  each  physician  who  had  attended  her  case  had 
given  an  unfavorable  prognosis.  He  hoped  that  we  would 
find  something  to  account  for  her  condition,  although  he  had 


80  OBIFICIAL  SURGERY. 

been  told  there  was  not  sufficient  pathology  within  the  pelvis 
to  so  affect  her  mind.  Her  history  gave  a  picture  of  a  hem- 
orrhagic  tendency  of  the  uterus  since  the  birth  of  her  first 
child  (which  was  still-born,  twenty  years  prior  to  this  inter- 
view). There  had  been  nine  pregnancies,  each  aborting  from 
no  apparent  cause.  Examination  revealed  laceration  at  in- 
ternal os,  a  slight  degree  of  anteflexion,  chronic  meteritis, 
and  the  boggy  feel  so  characteristic  of  malignancy,  also  a  sus- 
picion of  a  cystic  tumor.  The  patient  was  suffering  from  a 
valvular  heart-lesion.  Because  of  the  suspicion  of  malignancy, 
vaginal  hysterectomy  was  the  only  operation  that  could  be  con- 
sistently advised.  After  explaining  to  her  husband  the  dangers 
of  such  a  procedure,  he  decided  that  death  was  preferable 
to  hopeless  insanity,  and  he  would  take  this  one  chance  for 
restoration.  The  operation  was  therefore  ventured.  The 
fundus  proved  to  be  carcinomatous,  the  ovaries  and  tubes 
which  were  massed  by  inflammatory  exudate  were  totally 
removed,  as  was  a  cyst.  The  entire  operation  was  done  with- 
out clamp  or  ligature,  according  to  the  Pratt  method.  All 
denuded  surfaces  were  perfectly  coapted,  and  the  border  of 
the  broad  ligament  sutured  with  No.  1  catgut.  The  root  of 
the  vagina  was  tightly  pressed  against  the  base  of  the  broad 
ligament  and  held  in  position  by  silk,  against  which  was 
placed  sterilized  gauze  of  sufficient  quantity  to  produce  an 
even  pressure.  The  patient  bore  the  operation  remarkably 
well,  suffering  no  shock  thereafter.  For  the  next  three  days 
the  temperature  registered  100,  pulse  90  to  100.  In  the 
afternoon  of  the  third  day,  the  temperature  arose  to  103. 
Abdominal  tenderness  and  tympanitis  developed.  The  fol- 
lowing week  was  one  of  great  anxiety,  although  the  symptoms 
did  not  become  positively  critical.  A  few  days  later  the  pulse 
and  temperature  became  normal.  During  the  week  of  the 
peritonitis,  and  for  two  weeks  following,  the  mental  symp- 
toms passed  into  a  typhoid  condition,  with  occasional  periods 
during  each  day  of  perfect  mental  clearness,  when  she  would 
laugh  and  make  witty  remarks,  which  her  husband  said  was 
characteristic  of  her  in  her  younger  days.  These  seasons  of 


OKIFICIAL  SURGERY.  81 

improvement  became  longer,  until  her  mind  was  perfectly 
restored.  She  was  discharged  in  seven  weeks  after  her  opera- 
tion, a  cured  woman,  and  so  she  remains  to  the  present  time. 
Case  3. — Mrs.  M.,  age  34.  Had  puerperal  mania  after 
the  birth  of  her  first  and  only  child,  five  years  previous  to 
her  entrance  for  treatment.  Frequent  attacks  of  illusions 
and  hallucinations  occurred  during  the  five  years.  When 
she  was  brought  for  consultation,  she  was  indeed  a  candidate 
for  confinement,  having  been  pronounced  by  a  specialist  in 
mental  diseases  "a  hopeless  case";  and  when  he  was  con- 
sulted as  to  the  advisability  of  attention  to  the  pelvic  disorder, 
he  replied,  "It  will  be  money  thrown  away."  However,  the 
patient,  who  possessed  a  badly  lacerated  and  retroflexed 
uterus,  was  placed  in  our  care  and  we  repaired  the  cervix, 
at  the  same  time  removing  all  lesser  points  of  irritation  about 
the  orifices.  She  was  quiet  and  rational  for  three  days,  when 
an  aggravation  of  her  mental  condition  developed  until  she' 
became  unmanageable,  and  at  the  same  time  a  profuse  hem- 
orrhage occurred  from  the  uterus.  The  nurse  in  attendance 
very  wisely  packed  and  repacked  the  vagina  until  the  doctors 
arrived,  when  it  was  found  necessary  to  tie  the  uterine  arte- 
ries, as  sloughing  had  taken  place  about  the  cervical  stitches, 
extending  directly  into  these  arteries.  The  diseased  tissue 
was  at  the  same  time  scraped  away.  All  this  demonstrated 
that  the  organ  was  doomed  to  extirpation,  but  we  hoped  to 
have  a  few  days  after  this  procedure  to  make  up  for  loss  of 
blood  before  the  more  critical  operation  should  be  under- 
taken. The  mania,  however,  intensified,  and  the  hemorrhage 
again  commenced,  bringing  us  face  to  face,  about  midnight, 
with  a  patient  who  in  a  very  few  hours  of  acute  mania  would 
die  from  exhaustion  unless  something  was  done.  No  sooner 
was  the  position  appreciated  than  orders  were  given,'  and  with 
three  good  nurses  and  two  doctors  it  was  not  long  before 
our  little  patient  was  asleep,  and  soon  the  offensive  organ 
was  removed  and  the  patient's  life  still  preserved.  She  was 
quiet  for  a  few  days,  but  this  was  not  to  continue,  and  in 
the  three  week's  struggle  which  followed  it  seemed  that  two 


82  OBIP1CIAL  SUBGEKY. 

spirits,  one  commanding,  the  other  opposing,  possessed  her, 
each  fighting  for  supremacy.  During  this  time  it  was  nec- 
essary to  feed  her  with  a  nasal  tube.  At  the  end  of  three 
weeks,  when  failure  seemed  to  be  inevitable,  her  reason  began 
to  dawn,  appetite  became  natural,  sleep  refreshing,  and  a 
general  quietness  bespoke  victory.  Two  weeks  later  she  was 
delivered  to  happy  parents  in  her  right  mind;  they  tell  us 
that  she  has  been  perfectly  well  in  mind  and  body  ever  since. 


CHAPTER  VIII. 

ORIFICIAL   SURGERY  AND   THE   GENERAL   PRACTI- 
TIONER. 


MILTON  J.  BLIEM,  M.  D. 


There  are  specialists  and  specialists — and  yet  it  is  safe 
to  say  that  seven-eighths  of  the  whole  profession  do  still  and 
must  ever  cover  the  whole  ground  of  practice  in  general. 
While  the  surgeon  has  in  the  development  of  the  orificial 
philosophy  and  methods  found  an  extension  of  his  previous 
work,  the  general  practitioner  has  been  made  even  a  greater 
gainer.  Much,  of  course,  of  orificial  surgery  is  called  for  by 
local  orificial  conditions,  well  recognized  both  by  patient  and 
surgeon.  Such  conditions  were  clearly  defined  long  before  the 
origin  of  such  a  phrase  as  "orificial  surgery." 

To  my  mind  the  chief  and  all -important  benefit  of  orificial 
work  has  come  more  especiajJy  from  the  general  practitioner 
and  his  patients.  It  has  made  the  physician  more  vividly  con- 
scious of  the  existence  of  the  sympathetic  nervous  system  and 
has  opened  his  eyes  wide  to  the  wondrous  host  of  reflexes.  It 
has  placed  in  his  puzzled  hands  a  new  key  by  which  he  has  be- 
come able  to  unlock  and  explore  new  labyrinths  of  aetiology 
and  which  has  presently  led  him  to  the  happy  solution  of  the 
problem. 

It  is  in  the  general  practice  of  the  physician  that  the  meth- 
ods of  orificial  surgery  are  most  often  called  for.  May  I  not 


OEIFICIAL  SUKGERY.  83 

say  that  fully  one-half  of  our  prescribing  is  for  functional 
diseases,  many  of  them  chronic?  What  a  weary  round  of  doc- 
tors and  pills  do  the  victims  of  headaches  and  nervousness, 
dyspepsia,  neuralgia  and  constipation,  travel!  The  most  thor- 
oughly physical  examinations  fail  to  reveal  the  slightest  or- 
ganic lesion;  the  most  careful  prescribing  falls  short  of  giving 
permanent  relief.  Patient  and  doctor  are  at  their  wit's  end. 
How  many  physicians  would  (before  so  much  noise  was  made 
about  it)  have  thought  of  examining  the  rectum,  the  anus,  the 
introitus,  the  os,  the  cervix,  the  clitoris,  the  meatus,  or  the 
urethra  in  such  cases  ?  And  how  many,  even  if  led  to  examine, 
would  have  known  enough  to  recognize  what  they  did  see  and 
to  attribute  these  obscure  but  real  troubles  to  such  trivial 
things  as  pockets  and  papillae  or  inflamed  carunculae?  How 
changed  all  this.  If  in  these  days  a  patient  with  obscure 
symptoms  resists  the  best  efforts  of  the  physician  in  prescrib- 
ing, he  soon  directs  his  attention  to  possible  orificial  irritation 
as  a  cause.  In  many  cases,  to  say  the  least,  he  finds  what  he  is 
looking  for,  removes  it  and  cures  his  case.  Thus  orificial  sur- 
gery, at  least  in  its  simpler  forms,  has  become  a  sine  qua  non 
to  the  general  practitioner. 

Some  of  the  orificial  lesions  occasionally  found  by  physi- 
cians require  severe  surgical  operations,  demanding  the  high- 
est surgical  skill.  I  protest  against  ordinary  practitioners 
with  ordinary  surgical  skill  and  experience  undertaking  such 
operations.  I  believe  it  is  a  great  mistake  for  men  who  have 
never  done  any  general  surgery  to  rush  into  orificial  surgery 
and  attempt  to  run  the  whole  gamut  of  operations.  By  no 
means  should  the  general  practitioner,  unless  he  be  an  ex- 
perienced surgeon  also,  undertake  such  an  operation  for  in- 
stance as  either  the  Whitehead  or  the  Pratt  method  of  remov- 
— hi -reflecting  upon  this  ease  the  writer  speedily  realized 
ing  the  haemorrhoidal  area ;  nor  should  many  practitioners  at- 
tempt even  perineorraphy  or  trachelorraphy.  I  have  seen  these 
operations  done  by  surgical  novices  with  most  disastrous  re- 
sults. While  only  men  are  at  fault,  the  system  suffers  the 
blame. 


84  OBIFICIAL  SURGERY. 

However,  many  of  the  simpler  orificial  operations  can  be 
done  by  any  general  practitioner  who  is  capable  of  handling 
the  lancet  and  the  scissors  and  has  good  common  sense.  Hap- 
pily the  great  mass  of  orificial  cases  demands  nothing  more.  In 
this  lies  another  great  advantage  to  the  general  physician,  in 
that  he  is  able  to  operate  upon  the  majority  of  his  cases  him- 
self and  needs  not  refer  them  to  a  surgeon  specialist.  He  thus 
not  only  acquires  greater  surgical  skill  in  a  safe  way,  but  also 
adds  to  his  reputation  for  curing  his  patients  and  constantly 
widens  his  sphere  of  usefulness.  All  this  he  can  do  in  the  nat- 
ural course  of  his  practice  without  going  one  inch  out  of  his 
way  as  a  general  physician. 

In  conclusion,  orificial  surgery  bears  such  an  intimate  re- 
lation to  the  therapeutic  art  in  medical  diseases  that  no  gen- 
eral practitioner  can  afford  to  remain  ignorant  of  its  princi- 
ples nor  fail  to  accomplish  himself  in,  at  least,  the  simpler 
operations. 


SECTION  II. 


Philosophy  of 
Orificial  Surgery 


ORIFICIAL  SURGERY. 


CHAPTER  IX. 
THE  COMPOSITE  PHYSIOLOGICAL  MAN. 


E.   H.   PRATT,   M.    D. 


[This  chapter  is  rather  a  synopsis  of  Dr.  Pratt 's  book, 
"The  Composite  Man,"  which  is  a  most  charming  and  in- 
structive work.  I  would  advise  every  one  interested  in  Ori- 
ficial  Surgery  to  procure  this  book  and  read  it.  Published  by 
the  IT.  H.  Publishing  House,  Chicago.  Price  $2.00.— Editor.] 

The  human  form  consists  of  an  intricate  and  delicate  in- 
terweaving of  several  human  forms,  the  blending  together  of 
which  constitutes  the  individual  which  is  to  be  the  object  of 
our  study.  The  bones  which  form  the  framework  of  the  body 
have  a  head,  a  trunk,  a  spine,  arms  and  lower  limbs,  hands 
and  feet,  and  when  properly  adjusted  in  their  natural  position, 
so  perfectly  take  on  the  human  shape  as  to  merit  the  recog- 
nition of  the  fact  that  there  is  a  veritable  bony  man  in  every 
human  being.  Muscles,  too,  are  everywhere  present,  the  invol- 
untary type  forming  one  of  the  coats  of  all  the  tubular  struc- 
tures of  the  interior  of  the  body,  and  those  of  the  voluntary 
type  covering  the  head,  neck,  trunk  and  extremities  in  such 
symmetrical  manner  that  if  all  the  other  tissues  were  disen- 
tangled from  the  muscular  structures  the  muscles  would  con- 
stitute, when  placed  in  their  proper  relation,  a  veritable  mus- 
cular man.  The  great  central  artery  which  starts  at  the  heart 
and  the  veins  which  return  to  it,  visit,  by  their  branches,  ev- 
ery part  of  the  human  economy.  There  are  vascular  eyes, 
ears,  nose,  throat,  lungs,  intestines,  spine  and  extremities  in 


88  OBIFICIAL  SURGERY. 

each  human  being.  Were  all  the  other  tissues  carefully  dissect- 
ed from  the  vascular  system  without  disturbing  the  proper 
anatomical  location  of  the  blood-vessels,  the  shape  of  the  vascu- 
lar man  would  be  found  to  be  a  very  perfect  one.  In  the  same 
manner  there  exists  two  nervous  men — cerebro-spinal  and 
sympathetic,  a  lymphatic  man,  a  skin  man,  and  yet  another 
and  still  more  perfect  man  than  any  of  these  mentioned. 
There  is  a  tissue  in  the  human  body  so  representative  as  tc 
form  the  frame  work  of  all  the  other  men  and  also  to  act  as 
a  bond  of  union  between  them,  amalgamating  all  these  differ- 
ent structures  into  one  perfect  human  shape.  It  is  the  funda- 
mental element  of  the  skin  man  and  furnishes  a  covering  for 
the  bony  man.  It  forms  the  framework  of  all  the  interior  or- 
gans of  the  body  and  enters  into  the  formations  of  every  one 
of  the  other  men,  besides  welding  them  all  together,  thus  com- 
pleting the  structure  of  the  human  form.  The  name  of  this 
most  perfect  physical  man  is  the  areolar  man.  These  various 
men  are  all  thoroughly  dissected  and  studied  by  anatomists 
by  the  aid  of  the  scalpel  and  microscope  until  every  nook  and 
corner  of  the  human  body  has  come  under  repeated  and  accu- 
rate observation,  and  the  various  facts  with  relation  to  this 
human  house  are  thoroughly  classified  and  arranged  for  the 
guidance  of  students  in  medicine  and  surgery. 

Why  is  it  that  the  study  of  man  by  doctors  should  stop 
here,  however,  has  always  been  a  question  with  the  writer,  for 
it  leaves  unconsidered  the  most  important  of  all  the  men  whose 
delicate  blending  with  the  other  men  is  essential  to  the  knowl- 
edge and  practice  of  the  healing  art.  I  refer  to  a  man  still 
finer  than  the  areolar  man.  The  composite  man  as  already  de- 
scribed constitutes  nothing  but  a  corpse,  which  is  not  a  proper 
object  for  consideration  for  practitioners  of  medicine.  The 
presence  of  still  another  human  form  is  absolutely  essential 
to  the  necessities  of  medical  practice,  and  our  enumeration  of 
the  elements  of  the  composite  man  called  the  human  being 
will  not  be  complete  without  adding  the  spiritual  man  to  the 
list.  The  areolar  man  is  a  fine  one,  forming  as  it  does  the  basis 
of  all  the  other  physical  men,  but  the  spiritual  man  is  still 
finer  for  it  adds  the  element  of  life  to  the  areolar  man  itself. 


ORIFICIAL  SUEGEBY.  89 

Without  the  presence  of  the  spiritual  man  the  human  form 
would  be  simply  anatomy.  The  presence  of  the  spiritual  man 
changes  anatomy  to  physiology  and  adds  the  element  of  re- 
action which  makes  the  healing  of  the  sick  and  the  mainte- 
nance of  all  the  bodily  activities  possible.  The  dead  cannot 
respond  to  remedial  measures,  cannot  inflame,  cannot  undergo 
pathological  changes,  cannot  indulge  in  any  physiological  pro- 
cesses whatsoever.  It  is  only  as  the  cells  of  these  various  men 
are  living  that  they  can  become  sick  and  need  a  doctor.  When 
a  part  of  the  human  body  becomes  disordered  in  its  functions 
the  confusion  of  the  part  in  question  involves  all  of  the  va- 
rious men  whose  blending  constitutes  the  part.  In  a  felon,  for 
instance,  the  distress  of  the  affliction  is  visited  upon  the  bony 
finger,  the  vascular  finger,  the  lymphatic  finger,  the  skin  fin- 
ger, the  nervous  finger,  the  areolar  finger  and  upon  the  spir- 
itual finger,  and  why  the  medical  profession  should  consider 
the  morbid  states  of  the  material  finger,  and  entirely  ignore  the 
affliction  of  the  most  perfect  finger  in  the  composite  member 
is  a  question  which  must  present  itself  to  every  thinking 
doctor. 

The  consideration  of  the  orificial  philosophy  and  its  meth- 
ods involves  a  study  of  reflexes,  which  are  limited  only  by  the 
limitations  of  the  human  organization.  A  reflex  of  irritation, 
congestion  and  their  pathological  sequences  in  all  their  varie- 
ties may  occur  from  any  point  of  irritation  to  any  part  of  any 
one  of  the  various  men  enumerated  as  elements  of  the  com- 
posite man.  Any  bone  of  the  human  skeleton  can  suffer  from 
metastic  irritation.  Any  muscle  of  the  muscular  man,  any 
company  of  lymphatic  glands  of  the  lymphatic  man,  any  patch 
of  surface  of  the  skin  man,  any  cluster  of  capillaries  of  the 
vascular  man,  any  bundle  of  fibers  of  either  nervous  men,  any 
nest  of  meshes  of  the  areolar  man,  and  any  combination  of 
thoughts  and  feelings  which  are  characteristic  solely  of  the 
spiritual  man  can  suffer  disorder,  disintegration  and  even 
death  from  causes  remotely  distant.  Just  as  the  members  of 
any  human  family  can  be  prostrated  and  disorganized  by  un- 
welcome news  from  an  absent  member  of  the  household,  when, 
perchance,  the  occasion  for  the  disturbance  was  wholly  out  of 


90  ORIFICIAL  SURGERY. 

proportion  to  the  disastrous  consequences.  In  the  practice 
of  orificial  surgery  so  many  licentious  individuals  have  been 
made  virtuous,  so  many  irritable  natures  have  been  rendered 
amiable,  so  many  disordered  imaginations  have  been  correct- 
ed, so  many  aberrations  of  mind  and  heart  have  been  rectified 
that  to  ignore  the  presence  of  the  spiritual  man  in  an  ex- 
haustive series  of  articles  upon  the  orificial  philosophy  would 
be  an  unpardonable  omission.  Soul  and  body  are  so  closely 
knit  together,  so  inseparably  intertwined  that  it  is  impossible 
to  fairly  consider  the  earthly  habitation  of  a  man  without 
taking  into  consideration  the  man  himself.  Kemember  that 
we  are  doctoring  the  living  and  not  the  dead,  and  any  force 
which  affects  the  capillary  circulation  of  the  body  has  an  in- 
fluence upon  all  the  elements  of  the  composite  man  and  must 
be  taken  into  consideration  in  our  efforts  at  repair.  Material 
influences  are  proper  objects  of  our  study,  but  not  less  than 
these  are  those  wonderful  pulsations  of  thought  and  feeling 
that  blush  faces  and  pale  them,  that  start  sweat  glands  and 
dry  them,  that  accelerate  the  heart's  action  and  slow  it,  that 
affect  excretions  and  secretions,  and  that  by  their  constant 
play  either  induce  pathology  or  tend  to  re-establish  physi- 
ology. 

The  living,  composite,  physiological  man,  therefore,  is  our 
first  study  and  our  last  one.  It  requires  a  thorough  acquaint- 
ance with  it  in  all  its  characteristics  in  order  to  furnish  us  a 
standard  of  excellence  in  our  struggles  with  pathology.  In 
its  physiological  condition  it  is  continually  suffering  molecular 
disentegration  in  every  part  by  the  incessant  death  of  its  cel- 
lular elements.  It  is  also  experiencing  in  an  equal  degree  a 
perpetual  succession  of  molecular  births  for  the  daily  renewal 
of  its  forms  and  functions.  This  succession  of  changes  in 
structure  necessitates  a  constant  supply  of  new  material,  whose 
object  is  the  birth  of  new  cells  and  perpetual  funeral  trains 
for  the  burial  of  the  dead.  Food,  drink  and  air  supply  our 
hopes  for  the  future.  The  alvine  canal,  urinary  tracts,  the 
sweat  glands  and  our  expirations  relieve  us  of  what  has  been. 

These  bodily  activities  are  all  accomplished  by  the  blood 
stream,  which  contains  in  solution  the  food  for  the  complete 


ORIFICIAL  SUEGEEY.  91 

composite  man,  and  which  brings  away  in  its  return  current 
its  debris.    The  health  of  the  body,  therefore,  depends  solely 
on  the  perfection  of  its  system  of  supplies  and  removals.    In 
other   words,    capillary    circulation.      A    normal     circulation 
means  a  proper  digestion,  assimilation  and  appropriation  of 
food  and  a  complete,  thorough  and  continuous  renovation  of 
the  body;  and  therefore  the  beginning  of  all  pathology  is  an 
obstructed   or   insufficient    capillary   circulation.      To    possess 
a  universally  good  capillary  circulation  is  then,  to  be  in  a 
physiological   condition.      To   present    enfeebled   or   deficient 
capillary  circulation  is  to  institute  pathology.    The  capillaries 
are,  consequently,  the  battle  ground  between  health  and  dis- 
ease, between  life  and  death,  and  all  remedial  measures   in 
cases  of  disease  accomplish  their  purpose  by  restoring  a  normal 
capillary  activity.    The  history  of  medicine  is  a  record  of  bat- 
tles.    In  its  early  stages  will  be  found  three  great  remedial 
agents  which  were  almost  the  sole  reliance  upon  which  our 
ancestral   doctors  depended   for  establishing   capillary   circu- 
lation and  securing  a  restoration  to  health,  whether  the  disease 
to  be  overcome  was  a  local  or  a  general  one.    These  measures 
were  attacks  upon  the  alimentary  canal  by  means  of  emetics 
or  purgatives,  blisters  and  other  forms  of  counter  irritants  and 
the  lancet.     Every  additional  measure  which  has  been  sug- 
gested to  the  fraternity  for  the  relief  of  human  suffering,  since 
that  early  morning  of  medicine,  has  met  with  such  violent  op- 
position and  criticism  that  its  final  adoption  by  the  profession 
has  been  compulsory,  its  battle  being  won  by  a  series  of  con- 
quests against  prejudice,  bigotry,  intolerance,  and  all  the  other 
bad  elements  that  go  to  make  up  the  professional  weapons  of 
defensive  warfare.     Every  new  idea  in  medicine,  like  other 
births,  has  "leaped  with  a  wail  into  being,"  and  its  initiation 
into  full  recognition  in  the  profession  as  a  legitimate  means  of 
cure  has  been  a  severe  one. 

If  the  proposition  which  has  just  been  laid  down  be  once 
universally  understood  and  recognized,  medical  evolution  will 
speedily  become  an  easier  process  and  the  ailments  of  the  hu- 
man race  will  be  alleviated  with  corresponding  increase  in  ra- 
pidity. Truth  is  mighty  and  will  prevail,  even  though  learned 


92  ORIFICIAL  SURGERY. 

doctors  foolishly  essay  to  oppose  its  progress.  Successful  con- 
quests have  been  waged  against  professional  conservatism  un 
til  there  is  now  quite  a  number  of  measures  which  have  won 
their  way  to  good  standing  in  the  profession  as  a  legitimate 
means  of  healing  the  sick.  Massage,  baths,  electricity,  plasters, 
ointments,  heat  and  cold,  dieting,  artificial  and  natural  wa- 
ters, change  in  relations  and  surroundings,  mental  thera- 
peutics and  numerous  other  valuable  adjuvants  now  bear  the 
stamp  of  professional  sanction,  although  the  introduction  of 
each  measure  has  been  a  campaign  in  itself.  The  introduction 
of  the  orificial  philosophy  to  the  consideration  of  the  medical 
profession  furnishes  another  illustration  of  the  truth  of  this 
statement.  It  was  treated  by  the  profession  as  an  unwelcome 
child;  it  was  assailed  in  its  cradle,  scoffed  at  in  its  childhood 
and  ridiculed  in  its  youth;  but  its  manhood  has  come  and  it 
is  all  the  stronger  for  the  conquests  it  has  been  compelled  to 
make  against  contending  forces;  and  has  now  attained  such 
widespread  recognition  and  appreciation  that  it  feels  at  home 
in  the  list  of  accepted  remedial  measures  for  the  relief  of  hu- 
man suffering. 

The  presentation  of  its  basic  principles  and  their  method 
of  application  becomes  a  matter  of  extreme  pleasure  and  con- 
solation. As  all  the  influences  which  play  upon  the  circula- 
tion and  consequently  have  to  do  with  the  health  and  repair 
of  all  the  elements  of  the  composite  man  reach  their  destina^ 
tion  in  the  capillary  system,  whether  they  issue  from  mind  or 
matter,  by  means  of  nerves,  our  next  article  will  be  a  consid- 
eration of  the  two  nervous  systems,  in  their  mutual  relations 
and  separate  functions. 


CHAPTER  X. 

THE  MUTUAL  RELATIONS  AND  SEPARATE  FUNCTIONS 
OF  THE  TWO  NERVOUS  SYSTEMS. 


E.   H.   PRATT,   M.   D. 


Agreeable  to  our  promise  we  shall  discuss  in  the  present 
number  the  telegraph  and  telephone  wires  of  the  human  body. 
The  agencies  by  which  mind  speaks  to  matter  and  matter  re- 


OEIFICIAL  SURGERY.  93 

plies  to  mind.  The  wonderful  entanglement  of  life- wires  whose 
communications  thrill  the  whole  being  with  delight,  or  plunge 
it  into  the  depths  of  misery.  All  the  happiness  of  the  com- 
posite man  and  all  its  pains,  all  its  health  and  all  its  sickness, 
all  its  harmony  and  all  its  discord,  are  merely  messages  which 
traverse  the  life- wires,  one  extremity  of  which  reaches  upward 
to  the  inexhaustible  sources  of  being,  and  the  other  extremity 
of  which  is  grounded  in  every  part  and  particle  of  the  ma- 
terial organism.  As  these  remarkable  structures  are  the  means 
by  which  all  influences  from  within  and  from  without  are 
enabled  to  play  upon  the  various  tissues  of  the  body,  a  general 
consideration  of  their  structure  and  functions  will  furnish  an 
interesting  and  profitable  review  of  many  subjects  we  are  too 
prone  to  forget. 

The  universal  principle  of  duality  which  appears  to  exist 
in  all  created  things  finds  an  illustration  in  the  construction 
of  the  human  nervous  system.  The  two  general  parts  of  which 
it  consists  have  been  named  by  anatomists  the  cerebro-spinal 
and  sympathetic,  respectively,  and  while  each  of  these  parts 
has  separate  functions,  they  whisper  together  in  every  morning 
of  their  intention,  and  also  in  every  evening  of  their  accom- 
plishment. The  study  of  their  construction  and  mutual  rela- 
tions is  not  only  necessary  to  a  proper  understanding  of  all 
bodily  functions  and  activities,  but  is  also  of  thrilling  interest 
to  every  student  of  life. 

Let  us  for  a  moment  give  our  attention  to  the  cerebro- 
spinal  part  of  our  nervous  system.  Its  gray  matter  consists 
of  a  mass  of  cell  elements  so  numerous  and  closely  huddled 
together  as  to  form  by  their  association  a  considerable  portion 
of  the  structures  known  as  the  brain  and  spinal  cord.  The 
gray  matter  of  the  brain  surrounds  it  and  lines  it — it  is  its 
bark  and  its  heart.  Scattered  over  the  surface  of  its  convolutions 
and  sulci  in  several  layers  of  varying  thickness,  its  appearance 
has  induced  some  imaginative  anatomist  to  give  it  the  name  of 
cineraceous  or  ashlike  substance.  In  the  interior  of  the  brain, 
its  cells  are  crowded  together  in  ashy  heaps  called  ganglia, 
whose  names  are  mostly  fanciful  and  unimportant  in  the 
present  connection.  . 


94 


ORIFICIAL  SURGERY. 


In  the  spinal  cord  the  gray  matter  assumes  the  form  of 
two  lateral  crescents,  connected  by  a  short  commissure  which 
extends  along  the  center  of  the  cord  for  its  entire  length.  The 

white  matter  of  the  eerebro-spinal 
system  is  simply  a  mass  of  telegraph 
wires  connecting  different  parts  of 
the  brain  matter,  and  also  uniting 
the  gray  matter  with  every  part  of 
the  human  body  over  which  it  pre- 
sides. The  gray  matter  is  therefore 
the  headquarters,  the  central  office, 
of  the  cerebro-spinal  organization, 
and  the  white  matter  consists  of  a 
mass  of  telegraph  wires  which  carry 
its  messages.  If  the  cerebro-spinal 
structure  be  likened  to  a  tree,  its 
gray  substance  will  correspond  to 
the  roots  of  the  tree,  dripping  down 
deep  into  the  sources  of  being  from 
which  all  life  draws  its  inspiration; 
and  its  white  substance,  which  trans- 
mits the  vital  forces  to  the  ultimate 
tisues  of  the  body,  will  correspond 
to  the  trunk  and  branches  of  the 
tree,  which  carry  sustenance  to  its 
leaves  and  fruit.  But  the  cerebro- 
spinal  arrangement  is  not  equal  to  all 
the  requirements  of  the  body.  It 
wakes  in  the  morning,  lays  its  plans 
for  the  campaign  of  the  day;  walks 
the  body;  sits  the  body;  laughs  the 
body;  cries  the  body;  sweats  the 
body;  dries  the  body;  manipulates 
the  body  to  its  purposes  as  long 
as  it  will  endure  its  sovereignty 
and  obey  its  commands ;  but  when 
endurance  ceases  to  be  a  virtue,  and  bodily  languor  and  fa- 
tigue demand  a  respite  from  the  labors  of  the  day,  the  cerebro- 
spinal  ruler  throws  its  wearied  slave  upon  its  nightly  couch 


CEREBRO-SPINAL  SYSTEM. 


OEIFICIAL  SURGERY.  95 

and  suspends  its  activity  until  the  recuperative  processes  of 
nature  which  it  disdains  to  superintend  have  repaired  the  bod- 
ily damage  it  has  wrought,  and  furnishes  it  a  re-invigorated 
instrument  of  service  for  another  day's  employment.  The  ce- 
rebro-spinal  part  of  the  nervous  system  is  scarcely  to  be  re- 
lied upon  for  purposes  of  nutrition  and  repair.  Its  influence 
may  at  times  be  invigorating,  but  this  is  merely  incidental  to 
its  steady  and  deliberate  intention. 

In  hours  of  sleep  under  the  influence  of  anaesthetics  and 
narcotics,  in  the  hot  pursuit  of  the  day's  purposes,  the  bodily 
wants  of  renewal  and  burial  essential  to  its  continued  exist- 
ence would  be  sadly  neglected  were  they  not  more  faithfully 
sustained  by  another  and  more  reliable  supply  of  nerve  in- 
fluences. 

The  so-called  sympathetic  part  of  the  nervous  system 
seems  to  be  a  complete  organization  in  itself,  although  it  is 
possibly  merely  a  storage  battery  of  nerve  force,  arranged  for 
the  steady  and  uninterrupted  supply  of  nerve  power  for  pur- 
poses of  nutrition.  The  appearances  are  that  it  has  an  indi- 
viduality of  its  own — has  its  own  purposes  in  life,  its  own 
brains  and  means  of  accomplishment  of  those  purposes.  Its 
brains  consist  of  two  chains  of  ganglia  lying  parallel  in  front 
of  the  spinal  column  and  extending  from  the  base  of  the  crani- 
um to  the  coccyx.  There  are  four  ganglia  on  each  side  at  the 
base  of  the  skull,  associated  with  different  branches  of  the 
fifth  nerve.  There  are  three  in  the  cervical  region  and  for  the 
rest  of  the  way  down  there  is  but  one  ganglia  on  each  side  for 
a  vertebra.  In  front  of  the  coccyx  the  last  ganglia  of  each 
chain  have  joined  hands  to  make  one  good-sized  ganglion, 
called  the  ganglion  impar.  These  ganglia  are  connected  with 
each  other  by  nerve  trunks  and  also  communicate  with  the 
cerebro-spinal  nerves  as  they  issue  from  the  intervertebral  and 
sacrum  foramina,  while  yet  other  nerve  cords  wander  out  into 
the*  body,  forming  complicated  plexuses  about  the  heart,  and 
a  little  lower  down,  just  back  of  the  stomach,  congregating  to 
form  the  great  solar  plexus,  whose  rays,  following  the  arterial 
trunks,  extend  to  the  remotest  corners  of  the  body,  illuminat- 
ing their  dark  recesses  with  glad  tidings  of  food  and  drink  for 
their  daily  sustenance. 


96 


ORIFICIAL  SURGERY. 


The  adjoining  cut  presents  a  side  view  and  consequently 
one-half  of  the  great  sympathetic  nerve.     Like  the  cerebro- 

spinal  system  it  has  effer- 
ent and  afferent  nerves, 
the  former  of  which  bring 
to  the  headquarters  or 
ganglia  the  oft-repeated 
story  of  the  various  wants 
of  the  bodily  organs;  and 
the  later  of  which  are 
distributed  to  the  peculiar 
muscular  structures  whose 
office  it  is  to  supply  those 
wants.  "We  have  two  kinds 
of  muscular  structure,  one 
for  the  outside  of  the  body 
and  the  other  for  its  inter- 
ior framework.  The  outer 
muscles  pad  the  face,  neck, 
trunk  and  extremities.  The 
fibrillse  have  a  striated  ^ap- 
pearance under  the  micro- 
scope and  their  action  is 
dominated  by  the  cerebro- 
spinal  system  and  conse- 
quently is  under  the  con- 
trol of  the  human  will. 

Through  their  agency 
we  can  stand,  sit  or  re- 
cline; we  can  smile  or 
frown;  we  can  run  or 
walk:  we-  can  transport 
ourselves  from  one  point 
to  another;  avoid  dangers 
or  hasten  to  meet  tli£m. 
In  other  words,  can  urge 
the  body  along  the  path- 

SYMPATHETIC  SYSTEM.  WRy     Q£    jjf e    through     its 

cycles  of  years. 


OEIFICIAL  SURGERY.  97 

The  interior  muscles  form  one  of  the  coatings  of  all  the 
tubular  structures  by  means  of  which  the  processes  of  life  are 
carried  on.  The  intestinal  tract,  the  bronchial  tubes,  the  blood 
vessels,  the  lymphatics,  all  the  glandular  structures,  with  the 
exception  of  the  spleen  and  thyroid  and  the  sexual  and  urinary 
tracts,  are  supplied  with  a  muscular  coating  by  whose  action 
peristalsis  is  secured  and  bodily  activities  progress.  By  these 
tubes  we  live.  Supplies  are  brought,  waste  materials  are  carted 
away,  secretions  and  excretions,  air  and  blood  all  reach  their 
destination  and  are  propelled  on  their  way  by  these  minute 
muscular  structures. 

The  muscular  coats  of  these  tubes  are  arranged  in  layers 
so  that  the  fibers  run  in  two  directions,  longitudinally  and  cir- 
cularly. The  longitudinal  fibers,  when  they  contract,  shorten 
the  tube  which  they  cover,  while  the  circular  ones,  when  they 
contract,  constrict  it  so  that  by  the  combined  action  of  these 
two  sets  of  muscles,  vermicular  motion  is  secured  and  solid, 
liquid  and  gaseous  substances  are  kept  in  motion.  Under  the 
microscope,  the  fibers  of  these  interior  muscles  are  found  to  be 
non-striated  and  are  called  involuntary  muscles  because  they 
are  not  under  the  control  of  the  will.  They  are  supplied  solely 
by  the  sympathetic  nerve. 

When  the  afferent  nerves  report  to  the  ganglia  the  needs 
of  the  various  tissues,  a  response  comes  steadily  through  the 
efferent  or  motor  nerves  and  the  wheels  of  life  are  set  in  mo- 
tion to  feed  the  hungry,  furnish  drink  to  the  thirsty,  and  re- 
move the  crumbs  after  the  feast  is  over.  It  is  wonderful  ma- 
chinery. So  harmonious  does  its  clockwork  operate  that  the 
slightest  disorder  of  one  part  affects  in  sympathy  every  other 
part  of  the  organization. 

It  is  not  equally  active  at  all  times,  but  it  is  our  veritable 
clock  of  time.  It  is  wound  up  for  one  hundred  years  or  more. 
Our  poor  knowledge  of  how  to  care  for  it  and  the  recklessness 
of  our  selfishness  have  lowered  the  average  of  its  running  to 
thirty  odd  years;  but  whether  the  time  be  long  or  short,  the 
perpetual  motion  of  these  parts  of  the  machinery  of  our  life, 
these  tubular  structures  with  their  peristaltic  actions,  stimu- 
lated to  operation  under  the  inspiration  of  the  sympathetic 


98  OBIPICIAL  SURGERY. 

nerve,  are  the  means  by  which  we  run  our  brief  career.  They 
hold  the  various  parts  of  the  body  in  such  close  communication 
that  all  the  organs  enjoy  together  and  likewise  suffer  together. 

I  wonder  if  the  inspired  brain  that  named  the  nervous 
system  which  presides  over  peristaltic  actions  appreciated  the 
beauty  of  his  naming  when  he  called  it  the  "sympathetic" 
nerve,  from  "syn,"  together,  and  "pathos,"  suffering;  crys- 
tallizing in  anatomical  naming  the  fact  that  when  one  organ 
is  sick  all  others  are  conscious  of  the  fact  and  feel  more  or  less 
completely  the  depressing  influence  of  the  trouble.  In  re- 
capitulation, then,  the  cerebro-spinal  system  furnishes  us  with 
all  conscious  sensations,  our  special  senses  and  the  common 
one  of  touch  and  places  our  physical  organizations  at  our  com- 
mand for  the  purposes  of  life  as  they  prompt  us  to  action.  The 
sympathetic  nerve  furnishes  the  sensations  of  hunger  and 
thirst  and  orders  funeral  trains  for  the  removal  of  debris,  and 
prepares  our  food  and  drink,  digests  them,  circulates  them  and 
provides  in  every  way  for  our  bodily  necessities. 

One  point  should  be  a  little  farther  emphasized.  The' two 
parts  of  the  nervous  system,  the  cerebro-spinal  and  the  sym- 
pathetic, are  closely  associated  at  their  roots  and  distal  ex- 
tremeties.  The  first  branches  from  the  sympathetic  ganglia, 
wherever  located,  can  be  traced  wending  their  way  to  some 
cerebro-spinal  nerve  trunk  with  which  they  blend.  So  that 
every  ganglion  of  the  sympathetic  nerve  is  associated  with 
some  part  of  the  cerebro-spinal  system.  In  this  way  the  de- 
fenseless sympathetic  is  supplied  with  a  Court  of  Appeals.  If 
its  machinery  is  hopelessly  entangled  or  if  it  is  harmonious ;  if 
it  is  taxed  for  nervous  power  beyond  its  ability  to  supply  or  if 
it  bounds  with  the  spontaneity  of  health,  whatever  the  condi- 
tion of  its  work  or  play,  any  time  it  desires  to  do  so  it  can 
whisper  its  confidences  to  the  lordly  cerebro-spinal  system  and 
receive  its  sympathy  and  co-operation  or  be  hushed  into  sub- 
mission and  a  still  farther  endurance  as  that  structure  may 
elect. 

It  constitutes  itself  a  sort  of  bodily  conscience  which  like 
any  other  conscience  is  a  sure  guide  to  prosperity  and  happi- 
ness if  its  admonitions  are  only  heeded.  In  orderly  beings. 


OBIFICIAL  SURGERY.  99 

where  the  cerebro-spinal  system  respects  the  messages  from 
the  sympathetic  and  shapes  its  course  of  conduct  accordingly, 
the  system  is  never  overtaxed,  is  always  repaired  when  out  of 
order,  rests  when  tired,  is  active  when  rested  and  demon- 
strates its  possibilities  as  a  creature  of  divine  origin.  But  when 
the  cerebro-spinal  system  is  arrogant,  self-willed  and  incon- 
siderate, like  a  man  smothering  his  conscience  for  the  sake  of 
his  appetites,  and  refuses  to  listen  to  the  pleadings  and  re- 
quests of  the  sympathetic  system,  its  lawless  and  bulldozing 
conduct  sooner  or  later  brings  disorder  and  confusion  upon 
the  machinery  of  life.  The  body  is  unduly  prodded  to  action 
in  the  pursuits  of  gain  or  pleasure,  is  not  permitted  proper 
remedies  for  its  illness  or  proper  time  for  its  repairs,  and  con- 
sequently, slowly  by  degrees,  or  more  suddenly  in  some  unex- 
pected disaster,  succumbs  to  the  unnecessary  friction  of  ex- 
travagant and  unfair  demands  of  service.  If  the  sympathetic 
organization,  thus  unduly  taxed,  turns  like  a  worm  and  causes 
the  cerebro-spinal  to  suffer  disaster,  strikes  it  blind  or  deaf  or 
dumb,  makes  it  writhe  in  pain  or  stiffen  in  sclerosis,  it  is  sim- 
ply following  the  universal  laws  of  action  and  reaction  and  is 
but  to  be  expected. 

While  nutrition  is  therefore  provided  for  by  the  sympa- 
thetic system,  it  can  either  be  helped  or  interfered  with  ac- 
cording to  the  behavior  of  the  cerebro-spinal.  This  possibility 
is  achieved  by  the  mingling  of  the  roots  of  the  two  nervous  or- 
ganizations. But  their  leaves  also  touch.  Once  more  out  in 
the  duties  of  their  separate  lives,  they  mingle  in  common  ac- 
tion. The  cerebro-spinal  system  furnishes  the  special  sensa- 
tions, and  the  skin  with  the  common  sensation  of  touch.  It 
furnishes  all  the  voluntary  muscles  of  the  body  with  motor  in- 
fluence. The  sympathetic  nerves  are  distributed  to  all  the  mu- 
cous membranes  of  the  body,  furnishing  them  with  their  sen- 
sations, recognized  by  the  sympathetic  nerve  itself,  but  not  ap- 
pealing to  the  cerebro-spinal  system. 

The  motor  nerves  of  the  sympathetic  go  to  the  involun- 
tary muscular  fibers  and  these  preside  over  peristaltic  actions. 
But  beside  these  separate  functions,  the  two  nervous  systems 
intertwine  their  terminal  branches  in  plexuses  of  nerves  which 


100  OBIFICIAL  SURGERY. 

wrap  around  the  arterial  and  venous  trees  as  vines  cling  to  an 
oak,  following  the  great  trees  of  life  from  their  roots  at  the 
body  or  starve  them  by  constriction.  An  equal  privilege  by 
this  arrangement  is  furnished  to  the  cerebro-spinal  system.  It 
can  dilate  arteries  and  contract  them,  can  hasten  or  retard 
their  pulsations,  can  flush  the  capillaries  in  every  part  of  the 
heart  to  their  terminal  branches  in  the  capillaries,  so  that  the 
vermicular  motion  in  the  arteries  and  veins  is  provided  for 
by  the  entire  force  of  the  nervous  system.  The  plexuses  thus 
formed  are  called  the  vaso-motor  nerves.  Sympathetic  force 
can  start  the  heart's  action  or  stop  it;  can  blush  the  face  or 
pale  it;  can  sweat  the  body  or  dry  it;  every  thought  and  emo- 
tion which  it  entertains  clutches  the  coats  of  the  arteries  in 
some  form  of  self-love  or  widens  them  at  the  command  of  gen- 
erous impulses  as  it  may  elect. 

It  can  warm  the  extremities  with  the  pulsations  of  love  or 
freeze  them  with  the  constrained  action  of  hate ;  it  can  gladden 
them  with  throbs  of  good-will  to  fellow-man  or  depress  them 
with  communications  of  jealousy  and  greed.  On  the  banks  of 
this  arterial  stream  of  life  are  found  the  boundary  lines  be- 
tween mind  and  matter,  and  the  animal  and  the  spiritual,  im- 
personated in  the  sympathetic  and  cerebro-spinal  nerves,  hold- 
ing councils  of  peace  or  war  and  fluctuating  the  quotations  of 
the  commerce  of  the  body  according  to  the  decrees  of  their 
councils.  The  decisions  of  the  vaso-motor  system  prescribe 
the  blood  supply  perpetually.  It  is  well  for  us  that  the  cerebro- 
spinal  system  retires  at  night  from  these  councils  and  leaves 
the  management  of  the  vaso-motor  nerves  entirely  to  the  sym- 
pathetic, because  its  tendencies  are  too  wayward,  too  reckless, 
too  unreasonable,  too  selfish  to  exercise  an  unremitting  influ- 
ence upon  the  distribution  of  the  blood. 

So  much  for  the  separate  and  combined  spheres  of  action 
of  the  two  parts  of  the  great  nervous  system  which  keeps  the 
machinery  of  our  life  in  motion. 

The  next  article  in  the  present  series  will  present  some 
points  as  to  the  manner  of  nerve  distribution,  call  attention  to 
some  of  the  characteristics  of  the  sympathetic  nerve  and  ex- 
plain why,  in  using  the  term  "orificial  surgery,"  we  limit  its 
meaning  to  the  lower  openings  of  the  body. 


ORIFICIAL  SURGERY.  101 


CHAPTER  XI. 


SOME  POINTS  IN  THE  MANNER  OF  NERVE  DISTRIBU- 
TION, SOME  CHARACTERISTICS  OF  THE  SYM- 
PATHETIC NERVE  AND  THE  MEANING 
OF  THE  TERM  ORIFICIAL. 


E.   H.   PRATT,   M.    D. 


Hilton's  work  on  "Rest  and  Pain"  is  one  of  the  most 
practical  as  well  as  scientific  productions  in  medical  literature. 
If  it  were  more  generally  studied  and  appreciated,  and  the 
suggestive  thoughts  with  which  it  abounds  were  carried  still 
further,  practical  anatomists  would  be  more  numerous,  suc- 
cessful surgeons  greatly  multiplied  and  the  human  race  cor- 
respondingly benefited.  A  few  of  the  thoughts  in  the  present 
article  are  thoroughly  elaborated  in  this  work,  and  the  physi- 
cian who  aspires  to  a  thorough  knowledge  of  the  human  body, 
to  an  accurate  interpretation  of  its  aches  and  pains  and  to  a 
rational  application  of  remedial  measures,  will  do  well  to  be- 
come familiar  with  every  page  of  the  work. 

To  properly  understand  the  orificial  philosophy  and  its 
application  one  must  have  a  basis  in  anatomical  and  physio- 
logical facts;  and  the  failures  in  orificial  work  will  come 
mostly  from  the  ignorant  and  unscientific  practitioners  of  the 
philosophy.  In  the  narrow  limits  of  a  magazine  article  it  is 
impossible  to  present  with  any  degree  of  thoroughness  even 
the  foundation  principles  of  the  philosophy,  for  this  involves 
whole  treatises  upon  the  structure  and  functions  of  the  house 
we  live  in. 

More  or  less  of  a  thorough  medical  education  on  the  part 
of  the  readers  is  presumed  and  their  attention  attracted  merely 
to  new  associations  and  interpretations  of  facts  already  well 
known,  although  oftentimes  forgotten.  If,  by  the  present  se- 
ries, an  appreciation  for  Hilton's  valuable  volume,  Ranney's 
"Applied  Anatomy  of  the  Nervous  System,"  Mitchell's  "In- 


102  OEIFICIAL  SURGERY. 

juries  of  Nerves"  and  the  whole  list  of  works  upon  anatomy 
and  its  application  in  disease,  is  stimulated  to  increased  ac- 
tivity, at  least  one  worthy  purpose  will  be  served.  The  fact 
of  it  is,  that  it  is  not  surgeons  but  nature  that  cures  people. 
Nature,  in  fact,  often  performs  surgical  operations  upon  her- 
self wholly  unaided  in  her  work.  Many  a  time  she  amputates 
the  hemorrhoidal  inch  as  neatly  and  nicely  as  could  be  accom- 
plished by  the  American  Operation.  If  a  foreign  body  in  any 
part  irritates  her,  she  ostracizes  it  from  her  tissues  by  a  zone 
of  inflammatory  productions  which  imprisons  it  out  of  harm's 
way,  or  else  she  gradually  opens  her  tissues  by  disintegration 
until  she  completely  extrudes  it  from  her  temple. 

In  this  way  she  exfoliates  necrosed  bone,  draws  the  line 
of  demarkation  in  gangrene,  expels  biliary  and  urinary  calculi, 
removes  slivers  from  her  fingers  and  repels  hostile  attacks  of 
all  kinds  with  more  or  less  success.  In  fact,  a  surgeon  is  but 
nature's  handmaid,  whose  hand  and  head  are  employed  to  aid 
nature  in  her  efforts  at  recovery  when  otherwise  she  would 
cease  her  struggles  with  opposing  forces  and  succumb  to  dis- 
ease. Consequently  every  part  of  nature's  domain  is  intelli- 
gently organized  for  offensive  or  defensive  warfare  with  time 's 
destructive  forces. 

The  limbs  could  not  walk  were  not  the  various  muscles, 
membranes,  bones,  joints,  skin  and  other  structures  intelli- 
gently associated  so  as  to  work  in  harmonious  action.  The 
hands  could  not  successfully  accomplish  their  mission  in  life 
were  they  not  constructed  upon  the  same  intelligent  plan.  The 
voice  could  not  speak,  the  eyes  could  not  see,  the  ears  could 
not  hear,  the  whole  being  in  general  and  in  particular  could 
not  adapt  itself  with  any  success  to  the  uses  and  possibilities 
of  its  life  work,  without  an  intricate  and  complete  under- 
standing existing  between  all  its  parts. 

This  is  accomplished  by  means  of  the  nervous  system  men- 
tioned in  the  last  number.  There  is  a  common  principle  of 
nerve  distribution  to  which  attention  is  now  invited.  It  is  a 
principle  by  which  organs  associated  for  a  common  purpose 
are  supplied  by  pencils  of  nerves  emanating  from  a  common 
nerve  center  so  that  they  may  be  intelligently  associated  in 


ORIFICIAL  SURGERY.  103 

their  action.  In  the  cerebro-spinal  system,  for  instance,  where 
a  nerve  is  distributed  to  a  joint  surface,  another  branch  of  the 
same  nerve  passes  to  the  muscles  which  move  the  joint,  while 
still  another  branch  of  the  same  nerve  is  distributed  to  the  skin 
surfaces  covering  both  the  muscles  and  the  joint. 

Take,  for  example,  the  anterior  curval  nerve.  It  is  one 
of  the  nerves  of  locomotion  and  sensation  of  the  lower  extremi- 
ties. The  muscles  which  it  supplies  are  the  quadriceps  ex- 
tensor, the  psoas  magnus,  the  iliacus,  the  adductors  of  the 
thigh,  etc.,  and  as  these  muscles  in  their  action  move  the  hip 
and  knee  joints,  you  will  find  branches  of  the  anterior  curval 
nerve  supplying  both  of  these  joints  and  you  will  also  find  the 
skin  surfaces  covering  the  whole  anterior  and  inner  surface  of 
the  thigh  and  on  the  inner  side  of  the  leg  as  far  as  the  ankle, 
furnished  with  sensation  by  another  branch  of  the  same  nerve. 
An  inflammation  of  the  hip  joint  would  therefore  produce  a 
spasmodic  action  of  the  psoas  and  iliacus  muscles,  flexing  the 
thigh  upon  the  abdomen  and  producing  a  hyperaesthesia  of  the 
skin  in  the  region  of  the  groin,  thus  protecting  the  part  from 
injury,  furnishing  nature  with  an  intuitive  withdrawal  from 
harm's  way.  In  irritations  of  the  knee  joint,  the  quadriceps 
extensor  by  its  nerve  connection  is  made  sufficiently  tense  to 
interfere  materially  with  motions  of  the  joints,  struggling  to 
the  best  of  its  ability  to  secure  for  the  joint  physiological  rest, 
while  a  hyperaesthesia  of  the  whole  anterior  surface  of  the 
thigh  and  the  inner  part  of  the  leg  as  far  as  the  ankle,  warns 
all  intruders  that  the  parts  which  it  covers  are  ill  and  must 
not  be  disturbed. 

Illustrations  of  this  same  principle  occur  in  all  parts  of 
the  body.  In  the  face,  for  instance,  the  fifth  nerve  sends  a 
nerve  filament  to  the  glenoid  cavity,  supplies  with  motor  in- 
fluence the  muscles  of  mastication  and  with  sensory  influence 
the  entire  skin  and  mucous  surfaces  covering  and  lining  the 
face  and  jaws.  An  accurate  knowledge  of  the  distribution  of 
the  filaments  of  these  nerves  is  often  indispensable  to  a  cor- 
rect diagnosis  of  pathological  conditions  about  the  head  or 
face.  Is  the  pain  in  the  upper  or  back  part  of  the  ear?  The 
teeth  and  other  organs  of  mastication  have  nothing  to  do  with 


104  OBIFICIAL  SURGERY. 

it.  Is  it  in  the  lower  and  front  part  of  the  ear?  It  may  be 
caused  by  a  decayed  tooth.  Is  an  apparently  sound  tooth  in 
trouble?  It  may  be  induced  by  an  inflammatory  process  in 
the  lower  part  of  the  ear.  Is  trismus  present?  It  may  be 
caused  by  the  effort  of  a  growing  tooth  to  pierce  its  envelop- 
ing membranes.  The  birth  of  wisdom  teeth  is  very  often  ac- 
companied by  lock-jaw,  thus  illustrating  the  nervous  connec- 
tion between  the  joint,  the  muscles  which  move  it  and  the  skin 
or  mucous  surface  covering  it,  made  possible  by  the  law  of 
nerve  distribution  which  we  are  illustrating. 

These  illustrations  of  the  intelligent  nerve  distribution  in 
the  cerebro-spinal  system  by  which  the  various  organs  of  a  part 
are  enabled  to  act  in  harmony,  are  but  illustrations  of  a  plan 
which  is  equally  true  of  the  sympathetic.  The  male  sexual 
organs,  for  instance,  are  supplied,  not  by  a  single  nerve  trunk, 
but  by  a  pencil  of  nerves  coming  from  a  common  ganglionic 
center  and  passing  on  to  their  distribution  in  the  various  parts 
of  the  apparatus  they  are  to  dominate.  While  some  of  the  fila- 
ments supply  the  foreskin,  others  of  the  same  brotherhood  of 
fibres  are  distributed  to  the  corpora  cavernosa,  others  to  the 
corpus  spongiosum,  others  to  the  muscles  of  the  urethra,  oth- 
ers to  the  prostate  gland,  and  yet  others  to  the  testes  and 
scrotum;  thus  enabling  the  sexual  apparatus  to  erect  or  sub- 
side, to  perform  the  functions  of  sexuality  or  the  mere  utility 
of  urination  with  precision  and  intelligent  purpose. 

It  is  just  as  essential,  however,  to  a  proper  interpretation 
of  sexual  pathology  to  appreciate  the  mutual  influence  which 
one  set  of  terminal  nerve  fibres  exercises  upon  another  in  these 
parts,  as  it  is  to  be  familiar  with  the  nerve  distribution  of  the 
face  in  order  to  correctly  interpret  its  aches  and  pains. 

The  same  statement  will  apply  to  the  female  sexual  sys- 
tem. The  breasts,  the  clitoris,  the  meatus  urinarius,  the  vulva, 
the  vagina,  the  uterus,  the  Fallopian  tubes  and  ovaries  are  sup- 
plied by  a  sisterhood  of  nerve  cords  that  hold  these  separate 
parts  in  such  close  bonds  of  sympathetic  connection  that  one 
part  can  not  suffer  or  act  without  disturbing  the  whole  pencil 
of  nerves;  and  the  terminal  nerve  fibre  complaining  the  most 
is  not  a  true  index  to  the  starting  point  of  irritation.  Tumors 


ORIFICIAL  SUEGERY.  105 

of  the  breast,  for  instance,  are  repeatedly  removed  by  sur- 
geons when  the  cause  (which  is  usually  in  the  cervix  or  en- 
dometrium)  is  left  wholly  untouched.  Many  a  poor  mother 
suffers  untold  agonies  at  the  nursing  of  her  babe  from  her 
cracked  nipples  which  refuse  to  heal  under  any  form  of  local 
treatment,  while  the  cleansing  of  the  uterine  cavity,  which  is 
the  source  of  irritation,  perchance  would  restore  the  nipples 
to  their  normal  condition  in  a  few  days'  time  without  visiting 
upon  the  nipples  any  treatment  whatsoever. 

In  the  same  way  abnormalities  of  the  uterine  cervix  can 
express  themselves  in  urethral  irritations  and  so  on  through- 
out the  long  list  of  reflex  irritations  so  little  appreciated,  so 
poorly  understood  and  to  which  it  is  the  pleasant  duty  of  this 
Journal  to  repeatedly  call  attention  until  a  better  philosophy 
and  a  more  successful  practice  of  the  healing  art  be  universally 
inaugurated.  The  pencil  of  nerves  which  supplies  the  sexual 
system  of  either  sex  and  the  one  which  supplies  the  rectum 
are  so  closely  associated  that  it  is  impossible  to  cure  rectal 
troubles  when  unconnected  sexual  disorders  prevail  and  vice 
versa. 

Gynaecologists  must  respect  and  take  into  consideration 
rectal  conditions.  The  time  has  gone  by  when  they  will  be 
permitted  to  confine  their  attention  without  censure  to  the 
sexual  organs  alone.  A  large  percentage  of  these  troubles  are 
merely  reflex  from  rectal  conditions,  and  to  doctor  them  per- 
petually, persistently  and  unsuccessfully  without  even  examin- 
ing the  rectum  or  hunting  elsewhere  for  possible  causes  of  the 
obstinancy  of  the  case,  is  not  only  unskillful  and  unscientific, 
but  deserves  such  stronger  condemnation  as  is  implied  in  the 
words  dishonest,  dishonorable  and  in  every  way  censurable. 

Rectal  specialists  are  open  to  a  similar  charge.  To  per- 
petually prod  a  poor  rectum  when  its  congestion  and  irrita- 
bility is  but  voicing  sexual  disorder,  is  an  equally  grave  mis- 
take. Has  not  the  time  come  when  what  we  know  of  the  in- 
terlacings  and  intercommunications  of  the  nervous  systems, 
separately  and  collectively,  must  play  a  more  prominent  part 
in  our  diagnosis  and  treatment  of  disease?  Have  we  not  ar- 
rived at  a  stage  in  our  professional  development  where  we  can 


106  ORIFICIAL  SURGERY. 

be  more  positive  that  we  are  working  at  causes  and  not  sim- 
ply struggling  with  the  effects  of  disordered  functions? 

There  is  one  characteristic  of  the  sympathetic  nervous 
system  which  deserves  especial  consideration  in  the  present  ar- 
ticle, and  that  is  its  stupidity.  It  supplies  the  muscular  coats 
of  the  various  tubes  of  the  body  and  in  order  to  stimulate  them 
to  the  peristaltic  actions  for  which  they  are  intended,  it  is 
necessary  that  the  sympathetic  nerve  should  be  aroused  to 
activity  when  a  tube  of  the  body  is  distended  by  a  substance 
forced  into  it.  It  seems  perfectly  reasonable  that  a  bolus  of 
food  should  be  swallowed  and  carried  along  the  entire  twenty- 
six  feet  of  intestines  by  peristaltic  action  under  the  stimulus 
of  the  sympathetic  nerve.  It  seems  equally  reasonable  that 
when  the  heart  throb  expands  the  great  aorta  by  a  large  wave 
of  arterial  blood,  its  contracting  coats  should  carry  the  im- 
pulse as  far  as  the  ocean  of  the  capillaries.  When  saliva  or 
pancreatic  juice,  or  bile  or  urine  distends  the  canal  along 
which  it  is  to  pass,  it  seems  a  very  satisfactory  and  intelligent 
provision  of  nature  by  which  the  sympathetic  nerve  stimulates 
the  muscular  structures  involved  to  propel  the  liquids  on 
their  way. 

But  how  stupid  it  seems  for  this  delicate  nervous  system 
not  to  discriminate  between  the  distention  caused  by  a  sub- 
stance which  it  can  dispose  of  and  one  produced  by  a  swollen 
state  of  a  membrane  lining  one  of  these  tubes  which  it  sup- 
plies. The  purging  of  dysentery,  the  frequent  micturition  in 
urethritis,  the  perpetual  swallowing  in  oesophagitis,  the  in- 
cessant coughing  in  laryngitis  are  but  examples  of  either  in- 
nate stupidity  or  an  extreme  lack  of  education  on  the  part  of 
the  sympathetic  nerve,  evidently  mistaking  the  swollen  mem- 
brane for  a  substance  which  it  can  propel  along  the  tube  in 
question.  Owing  to  this  unfortunate  characteristic  of  the  sym- 
pathetic nerve  an  irritable  spot  in  any  tube  of  the  body  can 
induce  a  strictured  and  shortened  condition  of  the  tube 
caused  by  prolonged  contraction  of  the  circular  and  longi- 
tudinal fibres  of  the  muscular  coat  guarding  the  point. 

Were  wounds,  ulcerations  or  undue  frictions  liable  to  oc- 
cur indiscriminately  in  any  part  of  the  various  tubular  struc- 


ORIFICIAL  SURGERY.  107 

tures  of  the  body,  annoying  strictures  and  a  dangerous  clog- 
ging of  the  machinery  of  our  organism  would  be  of  more  fre- 
quent occurrence  than  it  really  is. 

But,  fortunately  there  is  a  principle  of  physics  that  lim- 
its our  danger  from  this  source  of  disaster  to  a  few  and  for- 
tunately accessible  portions  of  our  anatomy.  The  principle 
is  that  the  irritation  of  an  organ  starts  at  its  mouth.  It  is  at 
the  doorways  of  exit,  at  the  outlets  of  reservoirs  of  all  kinds, 
at  the  portals  of  departure  where  the  wear  and  tear  of  passing 
streams  write  the  story  of  the  crowding  at  their  egress.  The 
exits  of  the  human  body  are,  therefore,  the  places  where  the 
tubular  linings  are  most  subject  to  attrition  and  consequently 
present  the  hypertrophy  or  atrophy,  the  hyperaesthesia  or  the 
anaesthesia,  the  extremes  of  pathology  in  either  direction,  oc- 
casioned by  excessive  and  unremitting  friction.  These,  then, 
are  the  places  to  search  not  only  for  pathology  of  the  areolar 
tissue,  of  the  blood  vessels,  of  the  glandular  structures  and  of 
the  terminal  nerve  fibres  and  of  mucous  membranes ;  but  also 
for  undue  spasmodic  action  of  involuntary  muscular  fibres, 
thereby  disclosing  an  extravagant  waste  of  sympathetic  nerve 
force,  for  it  costs  nerve  force  to  hold  muscles  in  a  state  of  un- 
due contraction  perpetually. 

Standing  for  an  hour  fatigues  one  more  than  walking 
for  half  a  day ;  holding  an  arm  in  a  horizontal  position  for  fif- 
teen minutes  tires  one  more  than  any  alternating  form  of  arm 
exercise  followed  for  many  hours;  gazing  at  a  fixed  point  for 
any  length  of  time  is  painful  and  well  night  impossible  for  eyes 
that  are  capable  of  intermitten  employment  so  long  as  day 
lasts.  But  these  are  illustrations  of  cerebro-spinal  fatigue. 
The  same  is  true,  however,  of  the  muscular  structures  supplied 
by  the  sympathetic  nerve.  When  an  anus  is  sufficiently  at  re- 
pose to  alternately  relax  and  contract  with  the  rhythm  of  the 
breath,  to  safely  guard  against  the  escape  of  alvine  contents 
during  extreme  bodily  exertion  as  in  the  act  of  sneezing  and 
coughing,  but  at  all  other  times  to  relax  to  a  proper  degree  its 
undue  tension ;  when  a  uterus  fluctuates  the  tension  of  its  gate- 
way to  the  accommodation  of  a  menstrual  flow  or  other  func- 
tions of  its  existence,  when  a  sphincter  vesicae  and  constrictor 


108  OBIFICIAL  SUEGEKY. 

urethrae  can  exercise  just  enough  tension  to  accomplish  their 
purposes  without  a  prodigal  expenditure  of  nerve  force,  when 
the  terminal  nerve  fibres  that  entangle  themselves  about  the 
lower  openings  of  the  body  have  no  demands  to  make  upon  the 
general  reservoir  of  the  nervous  system  except  for  the  normal 
performance  of  their  duties,  the  human  body  is  well  poised, 
its  peristaltic  actions  are  all  normal,  its  reactive  powers  superb, 
the  happy  individual,  who  is  its  possessor,  is  a  perfect  speci- 
.men  of  human  kind  and,  if  these  conditions  continue,  will  run 
to  the  natural  terminus  of  a  well  rounded  life.  He  will  live 
until  his  life's  time-piece  runs  down  by  the  natural  law  of 
limitations,  unless  he  is  removed  by  accident.  He  is  wound  up 
for  one  hundred  or  more  years  and  is  an  example  of  perfect 
physique,  seldom  witnessed  in  our  degenerate  times.  But 
when  pathological  states  of  the  friction-exposed  linings  of  the 
lower  openings  of  the  body  induce  an  undue  contraction  of  the 
muscular  fibres  surrounding  them,  the  expenditure  of  sympa- 
thetic nerve  force  is  extreme,  for  it  is  unremitting  and  per- 
petual and  the  nervous  drain  thus  occasioned  soon  manifests 
itself  in  poorly  performed  functions  of  the  rest  of  the  body. 

These  lower  openings  are  openings  not  merely  for  the  or- 
gans of  which  they  are  the  exit,  but  are  openings  for  the  en- 
tire body.  The  waste  from  every  part  of  the  human  body  that 
is  extracted  by  the  kidneys  from  the  eyes,  ears,  nose,  throat, 
lungs,  etc.,  finds  its  exit  through  the  one  urethra.  The  solid 
debris  of  the  arms,  limbs,  trunk,  head  and  every  part  of  the 
human  anatomy  that  takes  the  form  of  foecal  matter  is  lodged 
in  the  colon  and  finds  its  exit  at  the  anus. 

The  sexual  force  that  gives  quality  to  every  organ  of  the 
body  is  spent  or  conserved  at  the  gateways  where  sexual  com- 
merce is  carried  on.  These  lower  openings  of  the  body,  there- 
fore, are  not  merely  openings  for  the  individual  organs  which 
terminate  in  them,  but  are  universal  gateways  in  which  every 
organ  in  the  body  is  most  thoroughly  interested.  For  this  rea- 
son their  influence  is  as  wide-spread  as  the  body  itself  and 
their  condition  but  an  index  of  the  whole  being.  No  wonder 
then  that  a  morbid  state  of  the  mucous  membranes  lining  the 
lower  openings  of  the  body,  with  its  accompanying  tension  of 


OEIFICIAL  SURGERY.  109 

sphincter  muscles,  implies  a  weakened  peristaltic  action  in  all 
the  tubes  of  the  body,  a  more  or  less  impairment  of  all  the 
functions  of  the  body,  a  lowering  of  its  vitality  and  implied 
inability  to  repel  invading  forces  be  they  microbes  or  tempta- 
tions. 

Under  an  anaesthetic  the  inlets  of  the  body  can  be  dilated 
or  manipulated  at  will,  the  various  cavities  can  be  opened  for 
curious  gaze,  the  limbs  can  be  amputated  and  joints  resected 
without  disturbing  the  rhythmic  flow  of  life  in  the  sleeping 
subject,  if  the  operative  procedures  stop  short  of  destruction. 
But  at  the  lower  openings  of  the  body  and  only  here  can  dilata- 
tion and  various  forms  of  operative  procedure  suspend  or 
arouse  the  breath,  empty  or  flush  the  capillaries,  in  short  hold 
as  in  a  balance  the  vital  spark  itself. 

The  majority  of  deaths  from  anaesthetics  occur  in  opera- 
tions upon  the  rectum  because  surgeons  pinch  these  tissues, 
suspend  respiration  and  do  not  know  enough  to  stop  the  pinch- 
ing and  permit  the  patient  to  live.  Nearly  all  of  the  deaths 
from  anaesthetics  occur  because  doctors  do  not  know  the  re- 
suscitating power  of  the  rectal  speculum  skillfully  handled. 
Similar  effects  can  be  produced  by  dilatation  and  manipula- 
tion of  the  sexual  orifices  although  not  so  certainly.  In  hand- 
ling these  lower  openings  of  the  body,  therefore,  the  surgeon 
is  not  merely  doing  local  work,  but  is  tampering  with  the 
capillaries  of  the  entire  system.  These  openings  are  the  mouths 
of  the  entire  body  and  whereas  the  principles  of  the  orificial 
philosophy  are  applicable  on  a  smaller  scale  to  any  organ  in 
the  entire  body,  these  openings  are  essentially  universal  in  their 
sphere  of  influence  and  are  consequently  the  only  ones  referred 
to  when  mention  is  made  in  general  terms  of  the  orificial  phil- 
osophy and  of  orificial  surgery. 


110  ORIFICIA.L  SURGERY. 


CHAPTER  XII. 


THE  PHILOSOPHY  OF  ''NUTRITION"  AND  THE  RELA- 
TION OF  ITS  DISTURBANCES  TO  AFFECTIONS  OF 
THE  NERVOUS  SYSTEM,  AND  THE  VALUE 
OF  ORIFICIAL  TREATMENT  THEREIN. 


W.    E.    BESSEY,    M.    D. 


There  are  certain  expressions  to  be  found  scattered 
through  the  medical  literature  of  the  past,  which  by  reason  of 
the  crystallized  terseness  of  statement  of  great  truths  con- 
cerning the  function  of  nutrition  may  be  accepted  as  axioms. 

A  citation  of  a  few  of  these  will  enable  us  to  outline  the 
accepted  thought  of  the  profession  and  the  biological  science 
on  this  subject  at  the  present  period.  The  first  one  of  these 
expressions  I  wish  to  quote  is:  "Nutrition  is  the  physical  basis 
of  life."  What  a  seed  thought  this  furnishes  us,  and  what  a 
world  of  meaning  it  conveys.  If  this  be  so,  then  the  condition 
of  the  nutrition  in  any  organism  must  be  the  true  standard  of 
its  physical  health,  and  the  disturbance  of  this  function  such 
as  are  expressed  in  the  words  ' '  mal-nutrition "  and  "mal-as- 
similation, "  must  of  necessity  be  regarded  as  potent  factors  in 
the  long  line  of  physical  ailments. 

This  inference  has  found  expression  in  the  annals  of  medi- 
cal lore  ir  the  following  form :  ' '  The  state  of  nutrition  in  any 
organism,  whether  it  be  plant,  animal  or  man,  determines  the 
physical  condition  of  that  organism." 

This  at  once  places  the  function  of  nutrition  first  in  the 
order  of  importance,  and  it  should  be  so  regarded,  and  studied 
by  all  who  are  responsible  for  the  health,  happiness  and  physi- 
cal condition  of  the  race.  If  this  position  were  assailed,  I 
might  quote  the  Greek  philosopher  (Aristotle)  who  wrote: 
"Nutrition  is  the  fundamental  condition  (basis)  of  all  vital 
action,  all  living  manifestation,  all  organizations,  all  growth 
and  development,  all  activity,  all  successful  human  action — in 
a  word,  all  life — be  it  vegetable,  animal  or  human." 


OBIFICIAL  SURGERY.  Ill 

Acting  upon  this  philosophy,  the  gardener  or  farmer  care- 
fully prepares  the  soil,  thoughtfully  (and  with  more  or  less 
scientific  knowledge)  manures  it,  and  furnishes  it  with  the 
best  kind  of  plant  food,  from  vegetable  decomposition  or  min- 
eral salts,  as  phosphates,  etc.,  possible  to  obtain.  And  likewise 
the  stock  breeder  resorts  to  "feeding"  to  improve  the  nu- 
trition, and  thus  perfect  the  physical  condition  of  his  animals. 
And  so  the  wild  animals  instinctively  select  their  food,  and 
this  faculty  still  lingers  in  the  domestic. 

But  man,  ever  at  variance  with  natural  law,  violates  every 
principle  of  common  sense  in  his  indulgences  in  eating,  and 
suffers  in  exact  proportion  to  the  extent  of  his  violation  of 
natural  law,  where  he  has  not  invoked  the  assistance 
of  his  fellow-man  belonging  to  the  noble  profession  of 
medicine  (which  man's  hygienic  sins  have  called  into  exist- 
ence) in  which  case  he  becomes  the  victim  of  a  thousand  ill- 
considered  and  maladroit  efforts  to  restore  normal  action  by 
the  ingesta  of  more  or  less  potent  drugs  which  add  their  own 
deleterious  and  injurious  effects  to  his  previous  derangements 
and  leave  him  a  physical  wreck  for  the  disciples  of  orificial 
principles,  a  wiser  and  more  rational  philosophy,  to  deal  with. 

When  the  normal  condition  of  the  digestive,  assimilative 
and  circulatory  organs  is  interfered  with  in  any  way,  defective 
nutrition  is  found  to  be  the  result,  and  this  defect  may  be  par- 
tial, affecting  certain  tissues  or  organs  only;  or  general,  af- 
fecting the  entire  organism. 

As  every  effect  has  a  cause,  so  every  organ  must  have  a 
source,  of  energy,  enabling  it  to  perform  its  functions.  Trac- 
ing this  to  its  source,  we  find  it  to  be  the  ganglionic  or  great 
sympathetic  system  of  nerves  (until  recently  but  little  studied 
or  understood)  and  impaired  function  to  be  due  to  defective 
enervation,  similarly  induced.  And  when  the  nutritive  organs 
suffer  or  the  trophic  nerve  influence  is  disturbed,  it  results  in 
a  condition  of  impaired  or  mal-nutrition. 

Thus  we  find  that  anything  which  interferes  with  the 
healthy  action  or  normal  condition  of  the  sympethetic  (called 
also  the  nerve  of  organic  or  vegetative  life)  disturbs  at  once 


112  OBIFICTAL   SURGERY. 

the  various  functions  of  the  body  and  nutrition,  including  di- 
gestion, assimilation,  circulation  and  excretion,  most  of  any. 

It  may  be  accepted  as  an  axiom,  that  while  a  liberal  blood 
supply  is  the  basis  of  nutrition,  yet  without  a  governing  nerve 
influence  there  could  be  no  trophic  action,  no  nutrition,  no 
growth.  Consequently,  the  twin  elements  which  cause  nu- 
trition are  blood  and  nerve  supply;  these  being  liberal  assimi- 
lation will  be  rapid  and  extensive ;  but  if  these  be  deficient,  as- 
similation will  be  correspondingly  defective,  or  if  disturbed,  it 
will  be  faulty ;  and,  moreover,  should  the  blood  supply  be  am- 
ple and  the  nerve  supply  defective  or  disturbed,  then  will  be 
observed  the  various  trophic  disturbances  to  which  nutrition  is 
subject;  namely,  atrophy,  hypertrophy,  dystrophy,  etc.  The 
only  conclusion  then  that  can  be  reached  is  that  nerve  influ- 
ence is  the  most  important  element  in  nutrition  and  all  cases 
of  defective,  or  mal-nutrition,  have  their  cause  in  defective  or 
perverted  nerve  force. 

In  this  connection  it  is  well  to  observe  also  that  it  is  upon 
this  ' '  corner-stone ' '  that  our  orifi cial  philosophy  is  based. 

Any  interference  with  this  source  of  automatic,  organic, 
vital  energy  results  at  once  in  disturbances  of  organic  func- 
tions and  impairment  of  nutrition  of  the  various  tissues  of 
which  the  physical  organism  is  composed.  It  cannot,  there- 
fore, be  denied  that  mal-nutrition  and  mal-assimilation  play 
important  parts  in  the  phenomena  of  disease. 

This  subject  leads  up  to  the  study  of  perverted  nutrition  of 
the  body,  or  its  parts,  brought  about,  or  apparently  brought 
about,  by  the  agency  of  the  nervous  system. 

These  may  be  termed  neurotic  dystrophies,  and  include 
conditions  of  over-nutrition,  and  conditions  of  under-nutrition 
(when  the  variation  is  in  quantity  rather  than  kind).  Then 
there  are  conditions  of  misdirected  nutrition,  or  eccentric  nu- 
trition, (where  the  variation  is  of  kind  as  well  as  quantity), 
and  this  may  be  best  illustrated  by  turning  the  attention  to 
neurotic  dystrophies  of  joints  and  muscles,  which  all  may 
study  for  themselves.  The  study  of  joint  lesions  and  their  ef- 
fects upon  the  nervous  system  in  producing  wasting  diseases 


ORIFIC1AL   SUEGEEY.  113 

is  one  of  the  very  greatest  importance  as  affecting  nutrition, 
but  it  is  impossible  to  consider  them  in  this  paper. 

Deranged  nerve  influence,  due  to  a  local  irritation,  I  be- 
lieve, will  account  for  all  the  dystrophies  which  exist,  through 
their  disturbing  influence  over  the  sympathetic. 

Irritation  of  a  nerve  filament  undoubtedly  results  in  ner- 
vous impairment  of  the  nerve  centre  to  which  it  belongs.  Then 
again,  irritation  causes  muscular  tetanic  contractions  of  the 
sphincters,  muscular  walls  of  the  urethra,  sexual  organs,  in- 
testines or  rectum  and  veins.  This  produces  in  turn  compres- 
sion of  the  nerve  filaments,  with  all  its  train  of  evil  conse- 
quences. And  as  in  spinal  paralysis,  in  which  the  injury  to 
the  branches  of  the  nerves  issuing  from  the  spinal  cord  (nerve- 
communicates) ,  and  uniting  with  the  vertebral  ganglia  of  the 
sympathetic,  affects  the  circulation,  favoring  bed-sores  on  the 
supposition  of  a  loss  of  not  only  direct  trophic  nerve  influence, 
but  also  a  loss  of  the  regulating  action  upon  the  blood  ves- 
sels, affecting  the  blood  pressure  in  the  part. 

These,  and  many  other  arguments  might  be  marshalled  to 
show  that  although  the  tissue  cells  nourish  themselves  by  im- 
bibation  of  nutritive  pabulum  supplied  to  them  through  the 
agency  of  the  capillaries,  or  blood  distributors — yet  those  meta- 
bolic changes  in  the  tissues  can  only  be  carried  on  under  the 
trophic  influence  of  the  nervous  system  and,  the  blood  supply 
with  its  nutritive  elements  can  only  be  carried  to  the  parts 
while  the  rhythm  or  tone  of  the  capillary  vessels  is  kept  in  a 
vigorous  condition,  through  a  healthy  action  of  the  vaso-motor 
constrictors  or  tonic  nerve  supply  to  their  walls,  and  that  this 
in  turn,  can  only  be  secured  by  securing  a  relaxed  condition  of 
the  rectal  sphincters,  and  freedom  of  the  lower  openings  of 
the  body  from  every  form  of  local  irritation.  And  therefore  in 
this  manner,  and  in  this  way  only,  is  the  key  to  nutrition  of 
the  human  body  held  in  the  hands  of  the  operator,  when  he 
takes  up  a  Pratt 's  speculum  or  other  form  of  rectal  dilator. 


114  ORIFICIAL   SURGERY. 


CHAPTER  XIII. 


THE  OBIFICIAL  PHILOSOPHY  AND  ITS  METHODS. 


E.   H.   PRATT,   M.   D. 


In  the  years  that  have  gone  by  since  the  promulgation  of 
the  orificial  philosophy  and  its  presentation  to  the  medical 
profession  for  their  consideration  and  employment  if  found  of 
practical  service  in  healing  the  sick,  there  has  been  no  attack 
worthy  of  mention  made  upon  it.  For  a  time  it  was  ridiculed 
by  some  and  ignored  by  others,  but  its  opponents  were  in- 
variably entirely  ignorant  of  what  they  were  opposing  and  con- 
sequently were  unworthy  of  attention,  as  active  ignorance  in 
the  course  of  time  becomes  self-conscious  and  is  shamed  first 
into  silence  and  then  repentance  for  its  manifold  mistakes. 

The  orificial  principles  are  based  upon  well-known  and 
universally  recognized  facts  of  anatomy  and  physiology.  But 
anatomy  and  physiology  are  merely  their  basis,  and  to  under- 
stand the  orificial  philosophy  requires  the  exercise  of  the  rea- 
soning faculties,  which,  as  a  rule,  are  so  poorly  developed  in 
medical  men.  Doctors  are  close  observers,  but  very  few  of 
them  are  philosophers.  They  are  frequently  well  posted,  but 
as  a  rule  they  are  poor  thinkers.  Their  memories  are  abund- 
antly stored  with  medical  facts,  but  most  of  them  are  slaves 
to  tradition  and  are  too  timid  to  think.  This  leaves  them  a 
prey  to  superstition  and  prejudice,  which  will  impede  their 
progress  until  a  more  liberal  general  education,  involving  the 
development  of  their  logical  powers,  shall  be  required  as  a 
necessary  preparation  for  the  study  of  medicine.  Ours  is  the 
age  of  emancipation  and  freedom  is  in  the  air.  Physical  slav- 
ery is  ended,  but  the  battle  against  mental  bondage  is  still  on, 
and  until  it  is  ended  the  orificial  philosophy,  like  every  other 
great  truth  arrived  at  only  by  the  exercise  of  the  reasoning 
faculties,  will  have  to  struggle  for  its  rightful  recognition. 
But  there  is  not  the  slightest  question  as  to  the  nature  of  the 
final  verdict.  The  orificial  philosophy  is  already  so  firmly  es- 


OEIFIC1AL   SURGERY.  115 

tablished  in  the  knowledge  and  active  practice  of  doctors;  it 
is  so  perfectly  invulnerable  as  a  philosophy;  it  is  so  valuable, 
indeed,  so  indispensable  to  the  cure  and  prevention  of  all 
forms  of  human  suffering;  it  is  such  an  absolute  necessity  for 
the  successful  practice  of  medicine  that  no  prejudice  can  stay 
its  progress ;  what  few  mistakes  may  be  made  in  its  applica- 
tion cannot  spoil  its  reputation,  but  simply  reflect  discredit 
upon  the  skill  of  the  incompetent  agent ;  no  greater  thought  in 
medicine  can  become  established  and  relegate  it  to  an  insig- 
nificant position,  for  it  is  so  broad  in  its  application  that  no 
truth  can  be  broader;  it  is  so  serviceable  that  none  can  be 
more  serviceable ;  it  is  so  emancipating  in  its  action  that  no 
measure  can  be  made  more  so;  and  beyond  all  question  it  is 
destined  to  sweep  the  entire  civilized  world  like  a  cyclone  un- 
til the  lustful  propensities  induced  by  sexual  irritation  which 
are  so  prodigal  of  sympathetic  nerve  force  and  irritability  and 
fear,  which  find  their  incipiency  in  rectal  troubles,  shall  be 
swept  from  the  race  and  universal  health,  which  is  the  natural 
condition  of  mankind,  shall  become  everywhere  permanent. 
The  hygiene  of  all  the  pelvic  organs  will  in  time  receive  its 
due  meed  of  attention  when  the  wonderful  cures  made  by 
orificial  methods  have  aroused  the  medical  profession  and  the 
people  to  a  realization  of  the  fact  that  what  can  be  cured  can 
be  prevented. 

The  act  of  respiration  is  the  central  expression  of  physical 
life.  The  vacuum  which  invites  the  air  to  the  lungs  also  acts 
as  a  force  pump  upon  the  fluids  of  the  body  and  draws  them 
from  their  peripheries  to  their  centres.  And  anything  which 
acts  upon  the  depths  of  inspiration  exercises  a  profound  in- 
fluence upon  the  circulation  of  the  blood  and  other  fluids. 
There  is  only  one  region  of  the  human  body  where  respiration 
can  be  in  the  slightest  degree  affected  by  manipulation,  and 
that  is  in  the  region  of  the  pelvis.  You  can  dilate  the  mouth  to 
its  utmost  capacity,  distend  the  nostrils  until  they  are  torn, 
stretch  apart  the  lips  until  they  give  way,  open  the  auditory 
canal  to  its  extreme  capacity,  trephine  the  skull,  open  the 
thorax,  invade  the  abdomen,  amputate  the  limbs,  grasp  ar- 
teries, or  nerves,  or  muscles,  or  arms  with  artery  forceps  and 


116  OEIPIC1AL   SURGERY. 

squeeze  them  to  their  destruction,  and  none  of  these  processes 
will  have  the  slightest  effect  upon  the  respiration  so  long  as 
life  remains  in  the  body.  Whoever  heard  of  a  spasm  of  the 
glottis,  or  diaphragm,  or  both,  produced  by  any  surgical  pro- 
cedure except  an  orificial  one?  This  power  to  influence  the 
depth  of  inspirations  and  thereby  control  the  circulation  of 
the  entire  body  is  peculiar  to  the  floor  of  the  pelvis,  and  can 
always  be  illustrated  by  dilatation  of  the  lower  openings  of 
the  body,  especially  the  rectum,  except  where  the  sympathetic 
nerve  itself  from  an  undue  nerve  exhaustion  has  passed  from 
a  normal  to  an  anesthetic  state. 

The  orificial  philosophy  is  so  true,  so  effective,  so  helpful 
to  mankind,  that  a  knowledge  of  its  basic  principles  and  meth- 
ods of  application  must  of  necessity  pass  on  in  the  course  of 
time  to  universal  recognition  by  all  healers  of  the  sick.  It 
may  be  in  our  time  and  it  may  be  later.  The  evolution  of  any 
great  truth  is  necessarily  a  slow  process,  but  it  is  none  the 
less  sure,  and  it  matters  little  to  us  whether  orificial  surgery 
receives  its  due  recognition  in  our  time  or  after  we  are  passed 
away.  Nothing  can  prevent  its  ultimate  triumph,  and  thank 
God  that  this  is  so,  for  certainly  the  world  is  badly  in  need 
of  it.  The  superficial,  patchwork  practice  of  medicine  of  the 
past,  and  in  too  many  instances  of  the  present,  has  had  its 
day,  and  although  what  good  there  is  in  it  will  still  be  em- 
ployed as  found  serviceable  for  purposes  of  temporary  relief 
a  deeper  healing,  born  of  a  broader  and  more  comprehensive 
conception  of  the  unity  of  the  human  body  and  the  mutual 
interplay  of  one  part  upon  another,  must  be  universally  de- 
manded. A  thought  that  has  such  a  deep  grip  upon  the 
fountains  of  life  as  to  be  capable  of  equalizing  the  entire  cir- 
culation of  the  blood  cannot  fail  to  affect  the  activity  of  every 
individual  particle  of  the  entire  body,  relieving  congestion 
and  correcting  anemias,  enriching  supply  currents  and  clear- 
ing away  debris,  melting  pathology  back  into  anatomy,  and 
re-establishing  normal  activities  universally. 

Such  a  thought  is  the  orificial  philosophy,  and  the  rapid 
progress  it  has  already  made  toward  universal  accomplish- 
ment. 


ORIFIG1AL   SURGERY.  117 

As  to  orificial  methods,  so  far  there  has  been  but  little 
change  in  them  except  as  the  several  operations  have  under- 
gone improvement  from  time  to  time.    The  method  of  circum- 
cision, or  repairing  the  cervix  and  perineum,  of  removing  the 
female  sexual   organs,  of  performing  the  American  and  slit 
operations,  have  all  been  more  or  less  improved  within  the  last 
few  years  until  all  the  objectionable  features  of  each  opera- 
tion have  now  well  nighf  disappeared.    But  no  single  method 
that  has  ever  become  well  established  for  carrying  out  the 
orificial  thought  has  as  yet  been  abandoned.     The  American 
operation  has  been  poorly  done  in  a  great  many  instances, 
and  in  all  probability  has  also  been  as  a  general  rule  over- 
done.   In  consequence  this  particular  operation  has  been  con- 
sidered a  vulnerable  point  of  attack  by  those  who  are  ignorant 
of  and  consequently  prejudiced  against  orificial  practices  gen- 
erally and  are  anxious  to  get  some  basis  for  assaulting  the 
thought  as  a  whole.     The  American  operation  has  been  vio- 
lently attacked,  slandered,   abused,  railed  against,  and  ever- 
lastingly condemned  in  the  most  violent  terms  by  an  army  of 
professional  mossbacks  who  thought  that  if  they  could  only 
annihilate  the  American  operation  they  would  accomplish  the 
extermination  of  the  entire  orificial  thought,  just  as  though 
the  value  of  a  thought  were  dependent  upon  an  imperfect 
means  of  carrying  it  out.     The  result  of  this  crusade  has  been 
to  diminish  the  number  of  American  operations  performed, 
which  was  to  be  desired,  for  this  operation  should  never  be 
employed  except  as  a  last  resort  and  when  every  other  method 
proves  to  be  unavailing.     But  nevertheless  there  are  cases  in 
which  the  American  operation  is  not  only  desirable  but  indis- 
pensable to  the  healing  of  the  sick.     Some  of  them  are  cases 
of  merely  local  trouble,  and  some  of  them  are  sufferers  from 
malnutrition  in  distant  parts  of  the  body.     To  all  such  the 
American  operation  has  been,  is,  and  always  will  be  a  Godsend, 
and  there  are  already  an  enormous  army  of  enthusiastic  pa- 
tients whose  lives  have  been  prolonged,  and  whose  physical 
miseries  have  been  ended  by  a  skillfully  performed  American 


118  ORIFIC1AL   SURGERY. 

operation.  As  a  result  of  this  severe  criticism  which  it  has 
sustained,  although  it  will  never  be  abandoned  it  will  be  more 
judiciously  employed  in  the  future  than  it  has  been  in  the 
past,  and  its  critics  have  done  a  kindly  service  to  orificialists 
themselves  as  well  as  to  humanity. 

The  question  as  to  whether  pockets  and  papillae  are  ana- 
tomical or  pathological  formations,  and  consequently  whether 
they  had  better  be  left  unmolested  or  removed  has  long  since 
been  settled,  and  the  ignorant  pretenders  to  a  knowledge  of  this 
subject  who  still  claim  that  they  are  important  physiological 
organs  are  now  merely  laughed  at  and  their  false  assertions 
fail  even  to  attract  attention.  No  one  has  ever  been  injured 
by  the  removal  of  pockets  and  papillae,  and  the  thousands  who 
have  now  submitted  to  this  procedure  have  been  so  universally 
and  so  wonderfully  benefited  that  the  practice  of  searching 
for  them  and  removing  them  when  present  is  becoming  very 
general,  even  with  those  who  do  not  appreciate  the  deep  mean- 
ing and  wonderful  scope  of  the  orificial  philosophy  as  a  whole. 
Pockets  and  papillae,  as  we  all  know,  are  by  no  means  uni- 
versally possessed  by  human  beings.  Many  have  from  one  to 
a  dozen  pockets,  some  have  from  one  to  six  or  eight  papillae, 
while  large  numbers  have  none  at  all.  But  whenever  they  are 
found  their  removal  is  always  attended  by  benefit  to  the  pa- 
tient. The  elaborate  discussion  of  this  subject,  published  in 
the  Journal  of  Orificial  Surgery  for  December,  1892,  covers 
the  entire  ground,  and  subsequent  observation  has  neither  add- 
ed to  nor  detracted  from  the  positions  taken  in  the  article. 

The  hysterectomy  which  the  orificialist  has  presented  to 
the  world  was  also  critically  scanned  and  misrepresented  and 
misunderstood  by  the  non-progressive  element  of  the  medical 
profession,  but  its  techniquqe  was  too  perfect,  its  reasonable- 
ness too  apparent,  and  its  results  too  satisfactory  to  afford 
any  substantial  basis  for  criticism,  and  there  is  no  longer  any 
doubt  as  to  its  superiority  over  all  other  methods  for  the  ex- 
tirpation of  the  female  sexual  organs  where  such  serious  work 
is  demanded,  or  of  its  being  ultimately  received  into  universal 
favor  by  all  practicing  gynecologists.  It  is  more  scientific, 
more  surgical,  more  effective,  less  dangerous,  and  in  every 


ORIFIC1AI,   SURGERY.  119 

way  more  satisfactory  than  any  other  method  of  removing 
the  uterus,  ovaries  and  tubes  in  vogue,  and  in  a  very  short 
time  it  must  completely  supersede  all  other  methods  by  those 
who  are  ambitious  to  excel  in  gynecological  surgery  and  give 
their  patients  the  benefit  of  the  best  the  world  has  to  offer  for 
their  relief. 

The  importance  of  securing  a  proper  condition  of  the  fore- 
skin for  the  boys  is  now  commonly  recognized  not  only  by 
doctors  but  by  the  laity.  And  in  the  last  two  or  three  years 
there  has  occurred  a  great  awakening  to  the  fact  that  a  corre- 
sponding benefit  can  be  secured  to  the  girl  children  by  proper 
attention  to  the  hood  of  the  clitoris. 

Sub-cutaneous  and  sub-mucous  stitching  has  grown  equal- 
ly in  favor  and  is  now  quite  commonly  practiced  by  orificial- 
ists  generally  wherever  it  is  practicable. 

In  another  respect  there  has  been  considerable  of  a  change 
inaugurated.  There  is  a  stronger  tendency  than  formerly  to 
avoid  surgical  interference  in  orificial  practice  and  to  rely 
more  upon  so-called  orificial  treatments,  deferring  operative 
interference  as  long  as  possible.  This  is  a  wholesome  tendency 
and  should  be  encouraged.  Surgery  is  destructive  and  should 
always  be  a  last  resort.  It  is  a  mere  apology  for  better  work. 
The  conservative  course  is  ever  the  true  one  to  follow,  and 
operations  should  be  resorted  to  only  after  all  other  means 
have  failed  and  they  are  demonstrated  to  be  a  positive  neces- 
sity. Too  much  has  been  expected  on  the  part  of  the  optimistic 
and  impulsive  natures  from  the  operation  itself  in  orificial 
work,  and  much  of  the  disappointment  and  failure  in  orificial 
work  has  been  due  to  this  fact.  Experience  soon  teaches  an 
orificialist  that  the  surgical  work  to  be  successful  must  be  fol- 
lowed by  systematic  after  attention  until  the  ideal  orifices  are 
attained,  namely,  those  which  are  dilatable  and  free  from  all 
forms  of  irritation.  The  majority  of  cases  had  better  remain 
untouched  than  to  be  merely  operated  upon  and  abandoned  to 
their  fate,  as  the  lower  openings  of  the  body  are  frequently 
left  in  a  worse  condition  than  before  by  operative  procedures 
unless  careful  and  intelligent  subsequent  local  attention  is  em- 
ployed to  secure  the  ideal  condition  sought  for. 


120  OEIFIG1AL   SURGERY. 

There  are  two  specialties  that  should  surrender  their 
titles  to  that  of  orificial  surgery,  namely,  the  rectal  and  the 
gynecological. 

Rectal  surgery  is  incomplete  and  ineffective  in  most  cases 
without  proper  respect  being  had  to  the  condition  of  the  sex- 
ual organs.  And  on  the  other  hand  gynecology  is  equally 
lame  and  abortive  if  the  condition  of  the  rectum  be  ignored. 
Orificial  surgery  unites  these  two  specialties  into  one,  and  at 
the  same  time  goes  beyond  both  of  them  in  its  one  great 
thought,  that  it  is  found  to  be  efficacious  not  only  in  correct- 
ing mere  local  conditions  of  the  pelvis  of  which  the  patient 
has  become  conscious,  but  at  the  same  time  is  more  ambitious 
in  its  scope  of  application,  for  it  enters  with  a  dominating 
power  the  general  bodily  element.  It  is  good  not  only  for 
pelvic  pathology  but  as  a  basis  of  cure  for  all  forms  of  chronic 
disease. 

CHAPTER  XIV. 


SCIENCE  OF  ORIFICOPATHY;  OR,  ORIFICIAL  METHODS 

OF  CURE. 


EUG.   HUBBELL,    M.    D. 


Life  is  the  manifestation  of  vital  force,  call  it  by  what- 
ever term  you  please,  and  is  pre-eminently  manifest  in  the 
the  cerebro-spinal  must  rest  from  its  activity.  Hence  the  vital 
force  must  be  resident  in  the  sympathetic.  The  sympathetic 
is  distributed  to  all  parts  of  the  body,  and  is  intimately  con- 
nected with  the  cerebro-spinal  (hence  the  well-known  law  of 
reflexes) .  It  sends  numerous  branches  that  end  in  the  orifices, 
especially  the  lower. 

Peripheral  nerve-irritations  or  impressions  are  trans- 
mitted to  the  centers,  or  through  communicating  branches  to 
other  nerves,  trunks,  and  centers.  Hence,  any  morbid  condi- 
tion of  the  orifices  must  irritate  the  peripheral  terminal  fibers 
of  the  sympathetic.  Continued  irritation  produces  nerve-waste. 


ORIFK/IAL    SUEGEBY.  121 

Sympathetic  nerve-waste  induces  functional  and  organic  de- 
rangement, especially  imperfect  circulation  and  respiration; 
hence  assimilation,  nutrition,  absorption,  secretion,  and  ex- 
cretion become  defective. 

Irritation  of  the  orificial  nerves  causes  contraction  of 
sphincters,  which  induces  local  congestions  and  inflammation, 
while  the  extremities  are  usually  cold  and  anemic.  The  ap- 
pearance of  the  orifice  of  a  tube  is  an  indication  of  the  con- 
dition of  the  other  end  of  the  same.  Example:  a  coated 
tongue  indicates  a  catarrhal  condition  of  the  stomach,  and 
red,  pouting  lips  of  meatus  urinarius  indicate  inflammation  of 
prostate. 

Having  thus  set  forth  these  well-known  principles,  what 
can  orificial  methods  do  toward  restoring  health  again?  It  has 
for  its  object  (as  one  would  naturally  infer)  the  removal  of 
the  morbid  condition  of  orifices,  allaying  the  irritation,  put« 
ting  at  rest  sphincters,  thus  stopping  nerve-waste, 
thereby  increasing  general  circulation,  restoring  assimilation, 
nutrition,  absorption,  excretion,  etc.,  by  permitting  the  vital 
force  free  sway  through  its  thoroughfares,  the  nerves. 

The  dilatation  of  the  sphincters,  especially  of  the  rectum, 
exerts  a  powerful  stimulant  to  the  vital  force  in  inducing 
greater  activity  in  the  circulation  and  flushing  the  capillaries. 
Good  circulation  means  good  nutrition.  Where  atrophy  of  the 
orifices  exists  the  slumbering  nerve-filaments  are  aroused  to 
activity  by  proper  use  of  orificial  methods.  Drugs  act  through 
the  nerves  upon  the  vital  force,  stimulating  or  depressing  it, 
as  the  case  may  be ;  so  with  heat  and  cold,  electricity,  massage, 
osteopathy,  mental  suggestion,  etc.,  all  sensitize  or  disensitize 
the  nerves,  thus  influencing  the  vital  force.  When  used  to 
resuscitate  the  drowning,  asphyxiated,  or  narcotized  patient, 
orificial  methods  are  marvelous. 

brificopathy  is  the  most  potential  method  we  possess  of 
awakening  the  dormant  forces  to  activity,  or  quieting  turbu- 
lent manifestations  into  peace. 

While  orificial  surgery  will  cure  thousands,  it  will  maim 
some,  if  not  carefully  used.  While  it  restores  many  to  their 
right  minds,  its  abuse  will  send  some  to  the  madhouse.  While 


122  ORTFICIAL    SURGERY. 

it  lifts  some  from  the  verge  of  the  grave,  it  also  kills.  Thus 
we  see  how  potential  a  means  it  is. 

If  some  of  you  say :  "If  it  occasionally  kills,  we  do  not 
want  orificopathy,"  let  me  refer  to  the  thousands  of  children 
and  infants  that  are  annually  slaughtered  by  drugs,  yet  no 
cry  is  raised,  and  we  go  on  in  the  same  way.  What  we  need 
is  more  care  and  painstaking  in  the  use  of  all  methods  of  cure ; 
I  care  not  whether  it  be  surgery,  medicine,  or  Christian 
Science. 

To  sum  up,  orificopathy  may  be  defined  as  a  method  of 
removing  irritation  and  quieting  excitability,  or  arousing  to 
activity  slumbering  sympathetic  terminal  nerve-fibres  located 
in  the  orifices  of  the  body,  overcoming  nerve-waste  and  estab- 
lishing free  action  of  the  vital  force  and  bringing  about  res- 
toration of  health. 


CHAPTER  XV. 


ORIFICIAL  PHILOSOPHY. 


C.    E.    SAWYER,    M.    D. 


Philosophy  is  the  science  of  principles.  Principles  are  the 
fundamental  elements  upon  which  all  superstructures  rest. 
The  scientific  application  of  orificial  principles  is  therefore  the 
key  to  whatever  in  success  or  failure  comes  to  us  as  orifioial 
surgeons. 

While  the  practice  of  orificial  surgery  is  comparatively 
new,  the  philosophy  upon  which  it  is  based  is  as  old  as  man; 
and  although  its  principles  have  been  obscured  until  recently 
by  the  mist  of  inexperience  and  ignorance,  observation  teaches 
that  they  have  ever  existed  and  because  of  their  relation  to 
life  itself  they  are  everlasting.  From  these  propositions  may 
be  gleaned  not  only  the  importance  of  orificial  philosophy, 
but  as  well  the  relation  the  principles  bear  to  the  cure  of  dis- 
ease and  the  security  of  the  foundation  upon  which  orificial 
surgery  is  built. 


ORIFICIAL    SURGERY.  123 

No  matter  the  vocation  in  life,  the  laws  which  govern  are 
but  the  evolutions  of  time,  a  working  over  as  it  were  of  basic 
principles,  improvement  upon  former  plans  rather  than  the 
introduction  of  new  ones.  Generation  after  generation  de- 
velops its  own  searchlights,  and  as  each  grows  in  power  the 
shadows  of  obscurity  become  less  marked.  Things  which  yes- 
terday were  unrecognized  and  unknown  are  clearly  perceptible 
today ;  the  theories  of  the  past  are  the  realizations  of  the  pres- 
ent and  the  progress  made  evolutionizes  all. 

The  river  Clyde,  in  Scotland,  has  for  many  generations 
been  the  home  of  ship-builders,  and  everything  from  a  hollow 
log  hewn  out  with  a  stone  axe  to  the  present  "ocean  grey- 
hound" has  found  its  origin  there.  In  comparison  along  this 
line  we  note  the  prodigious,  almost  inconceivable,  development 
which  has  been  made,  and  yet  we  are  at  once  struck  with  the 
fact  that  the  Campania,  with  its  thirty  thousand  horse-power, 
and  the  Deutschland,  with  all  its  magnificence  and  speed,  are 
but  the  evolution  of  experience,  the  working  over  of  the  same 
principles  which  were  embodied  in  the  tree-trunk. 

Every  epoch  in  the  history  of  the  world  has  had  some  one 
to  introduce  anew  and  to  reapply  the  principles  of  the  past. 
To  Dr.  Pratt  was  given  the  privilege  of  disclosing  to  the  medi- 
cal profession  orificial  philosophy  and  the  means  of  operation 
upon  these  principles  successfully.  The  philosophy  he  evolved 
was  not  an  invention,  but  rather  the  development  of  principles 
so  great  as  to  affect  life  in  all  its  complexities,  both  in  health 
and  disease;  an  awakening,  as  it  were,  of  principles  and  poli- 
cies which  had  remained  unrecognized  until  his  genius  and 
foresight  revealed  their  power  and  force  to  the  waiting  world. 

A  glance  at  the  development  and  widespread  recognition 
of  orificial  philosophy  demonstrates  the  greatness  of  its  basic 
principles,  for  without  a  solid  foundation  the  immense  super- 
structure which  has  been  the  outgrowth  of  persistent  effort 
and  painstaking  care  would  not  be  possible.  That  we  may  not 
forget  the  grounds  upon  which  orificial  surgery  is  based,  I 
think  it  well,  even  at  the  expense  of  repetition,  to  pass  in  re- 
view a  few  of  the  cardinal  principles  of  orificial  philosophy, 
in  order  that  we  may  again  satisfy  ourselves  of  the  stability 


124  OEIFICIAL   SURGERY. 

of  our  position  and  the  certainty  of  the  continuance  of  orificial 
surgery. 

Health  and  life  itself  depend  upon,  first,  the  quality  of 
the  blood  and  its  proper  circulation.  Second,  normal  peri- 
staltic action.  Third,  regulated  sympathetic  nerve  supply. 

These  are  the  principles  which  must  be  admitted  by  all 
to  be  the  fundamental  ones  underlying  whatever  in  health  or 
disease  comes  to  man.  If  they  are  operating  properly  and  in 
conformity  to  the  requirements  of  nature,  health  is  their 
product.  If,  on  the  other  hand,  they  are  operating  out  of  line, 
disease  is  the  consequence. 

With  such  principles  as  these  to  guide  in  the  administra- 
tion of  orificial  surgery  there  is  no  question  as  to  its  efficacy, 
and  with  such  elements  to  substantiate  there  is  no  doubt  as  to 
results. 

Fortified  with  these  principles  well  inground  we  need 
have  no  fear  of  failure,  and  if  our  cases  are  dealt  with  on 
these  basic  principles,  success  is  sure  to  follow. 

Experience  teaches  that  orificial  methods  control  these 
three  elements  of  life  perfectly;  as  to  the  certainty  of  this  we 
have  had  many  demonstrations,  for  year  after  year  at  these 
clinics  we  have  had  proof  upon  proof.  And  the  multiplied  ex- 
perience of  each  of  us  individually  has  grounded  us  more  firm- 
ly in  the  power  of  the  means  and  the  effect  they  have  in  the 
readjustment  of  disturbed  body  function. 

The  following  cases  are  cited  to  demonstrate  the  effect- 
iveness of  orifieial  methods  applied  according  to  orificial  phil- 
osophy in  my  own  field  of  work,  and  they  are  only  a  few  of 
many  of  a  like  kind  which  could  be  given : 

A  year  ago  a  boy  sixteen  years  old  presented  for  con- 
sultation. A  more  distressed,  cadaverous-looking  object  I  have 
never  met.  In  height  he  was  that  of  the  average  youth  of  his 
age.  In  appearance  he  was  old  as  a  centenarian.  His  drawn 
expression  and  staring  look  haunt  me  yet.  He  weighed  47 
pounds.  His  pulse  was  beating  at  the  rate  of  140  beats  per 
minute.  His  breathing  was  rapid  and  superficial.  He  had  a 
profuse  watery  diarrhea,  most  offensive  in  character.  The 
flesh  on  the  toes  of  one  foot  had  sloughed  away,  while  the 


ORIFIC1AL   SUEGERY.  125 

other  was  swollen  to  twice  its  normal  proportion  and  was  ul- 
cerated in  several  places.  The  skin  was  dry  and  scaly.  His 
hair  had  nearly  all  fallen  out  and  everything  about  him  bore 
evidence  of  malnutrition  in  a  most  aggravated  form.  Physical 
examination  of  the  blood  revealed  2,000,000  red  corpuscles  to 
the  cubic  millimeter,  with  almost  as  many  white  ones.  The 
specific  gravity  was  1036,  the  percentage  of  hemoglobin  being 
42  per  cent.,  about  as  poor  a  condition,  it  seems,  as  could  pos- 
sibly exist.  His  appetite  was  gone  and  there  seemed  to  be  no 
means  of  replenishing  his  vital  store. 

An  adherent  foreskin  and  a  tightened  sphincter  were  the 
only  cue  to  orificial  requirements.  As  anesthesia  was  out  of 
the  question,  the  means  of  treatment  had  to  be  limited  to  the 
simplest  form,  and  consisted  of  careful  retraction  of  the  fore- 
skin with  frequent  dilatation  of  the  sphincters  ani.  With  a  line 
of  after-treatment  consisting  of  oil  rubs  and  such  joint  move- 
ments and  massage  as  could  be  borne,  the  tide  of  affairs  slowly 
began  to  turn,  and  with  a  daily  repetition  of  these  means  for 
three  months  there  came  out  of  this  woebegone  specimen  of 
suffering  humanity  a  youth  of  average  weight  and  form.  It 
is  unnecessary  to  say  that  numerous  doctors  had  been  em- 
ployed, that  drugs  and  tonics  of  every  description  had  been 
used,  that  dietetic  regimen  of  various  kinds  had  been  em- 
ployed, and  still  the  chain  which  held  him  prisoner  had  not 
been  loosened  until  the  adherent  foreskin  and  the  tightened 
sphincter  had  been  relaxed.  Words  are  inadequate  to  express 
either  the  transformation  of  the  child,  the  gratitude  of  the 
parents  and  friends,  or  my  own  surprise  and  satisfaction. 

Here  was  a  case  which  had  defied  all  ordinary  means. 
One  in  which  the  blood-making  processes  were  so  interfered 
with  as  to  stop  all  growth  and  repair.  In  consequence  of  which 
the  operation  of  every  organ  of  the  body  was  more  or  less  dis- 
arranged, and  yet  this  simple  attention  was  sufficient  to  start 
anew  proper  physiological  function.  Regular  blood  tests 
showed  a  constant  improvement  of  the  quality  and  relation  of 
the  different  constituents  of  the  blood.  A  steady  slowing-down 
of  the  circulation  and  respiration  demonstrated  the  effect  up- 
on heart  and  lungs,  and  the  case  with  its  final  results  proved 


126  ORiFIG'IAL   SURGERY. 

the  efficacy  of  orificial  methods,  based  upon  the  philosophic 
principle  of  blood  supply. 

A  case  demonstrating  the  effect  of  orificial  surgery  upon 
peristaltic  action  is  the  following: 

Mr.  G.  C.,  an  active  and  prominent  business  man,  had  for 
five  years  been  the  subject  of  what  was  diagnosed  recurring 
attacks  of  la  grippe.  These  spells  were  usually  ushered  in  by 
a  hard  chill,  fever,  profuse  sweat  and  extreme  exhaustion. 
Such  had  been  their  severity  and  the  frequence  of  their  repe- 
tition that  the  patient  was  wholly  incapacitated  for  any  kind 
of  business,  often  being  confined  to  his  room  and  bed  for  weeks 
at  a  time.  He  was  obstinately  constipated,  his  appetite  poor, 
his  temperature  usually  subnormal,  extremities  cold  and  ev- 
erything about  his  appearance  indicating  the  extreme  pros- 
tration from  which  he  was  suffering.  Like  most  cases  that 
have  been  a  long  time  sick,  almost  every  means  had  been  em- 
ployed for  his  relief.  He  was  brought  to  the  sanitarium  on  a 
cot,  and,  as  his  family  physician  afterward  told  me,  none  of 
his  friends  expected  to  see  him  return  home  alive.  Physical 
examination  revealed  a  nodulated  condition  of  the  entire  colon, 
which  I  at  once  diagnosed  as  retained  fecal  matter.  The 
sphincters  ani  were  much  relaxed  and  the  pile-bearing  inch 
was  one  mass  of  hemorrhoidal  growths.  When  he  attempted 
to  have  an  evacuation  of  the  bowels  this  large  mass  of  tumors 
and  prolapsed  gut  would  come  down  and  become  strangulated. 

From  the  intense  pain  thus  produced,  bowel  movement  be- 
came next  to  impossible.  With  a  temperature  at  97,  a  pulse 
rate  at  120,  with  extremities  cold  to  the  knees,  the  face  pinched 
and  hippocratic,  I  put  him  under  an  anesthetic  and  proceeded 
at  once  to  relieve  the  condition  which  I  felt  sure  was  sapping 
his  vitality.  Ordinarily  the  slit  method  in  such  cases  is  pref- 
erable, but  in  this  case  I  decided  that  nothing  but  the  Ameri- 
can would  do.  No  sooner  had  the  flap  been  fairly  begun  than 
the  bad  symptoms  began  to  clear  up,  and  by  the  time  the  op- 
eration was  completed  the  temperature  had  risen  to  normal 
and  the  pulse  dropped  twenty  beats  per  minute. 

The  storm,  however,  was  not  over,  for  the  following  day 
the  symptoms  of  collapse  returned  and  for  the  next  seventv- 


ORIFK/IAL    SURGERY.  127 

two  hours  his  life  hung  by  the  narrowest  thread.  So  great 
was  the  shock  that  it  seemed  impossible  that  he  would  survive 
the  storm.  Looking  over  the  site  of  operation,  I  found  a  re- 
tained blood  clot  which  was  causing  a  great  deal  of  pressure 
and  tension.  Believing  this  to  be  the  cause  of  the  complica- 
tion, I  removed  two  or  three  stitches  and  curetted  the  clot 
away.  From  this  time  on  everything  was  more  favorable,  and 
in  less  than  a  month  this  man  was  back  at  his  desk  and  at 
work. 

I  omitted  to  state  that  for  ten  years  before  the  operation 
he  had  never  had  a  natural  bowel  movement.  From  the  time  of 
the  operation  (now  three  years  ago)  up  to  the  present  he  has 
never  had  to  use  any  assistance  to  bring  about  a  favorable 
movement  of  the  bowels  and  his  attacks  of  la  grippe  have 
never  returned.  This  was  unquestionably  a  case  of  autoinfec- 
tion  from  a  lack  of  proper  peristaltic  action  of  the  intestinal 
tract,  and  the  results,  which  have  been  so  highly  satisfactory, 
surely  warrant  the  conclusion  that  the  methods  employed, 
based  upon  the  second  law  of  our  philosophy,  are  equal  to 
the  most  trying  emergencies. 

As  a  case  illustrative  of  the  influence  of  orificial  methods 
on  sympathetic  nerve  force,  I  would  cite  the  following: 

Mrs.  L.,  aged  thirty-six  years,  had  become  a  nervous  wreck. 
She  was  a  highly  educated  and  intellectual  woman.  Forcible 
and  determined,  but  withal  congenial  and  agreeable.  A  leader 
in  society.  Within  the  year  preceding  her  coming  under  ob- 
servation she  became  morose,  petulant,  fault-finding,  worrying 
about  things  which  did  not  exist,  and  complaining  without 
cause.  Wakeful  by  night  and  restless  by  day,  she  was  in  a 
constant  condition  of  nervous  disquietude.  She  was  pale, 
anemic,  appetite  poor,  bowels  constipated,  urination  frequent 
and  painful,  menstruation  irregular,  all  of  these  conditions 
having  grown  gradually  worse  until  she  had  become  a  bed- 
ridden invalid. 

Physical  examination  revealed  an  atrophied  uterus  with 
a  very  irritable  and  congested  os.  As  local  treatments  had 
be»'ii  employed  without  effect,  and  all-round  orificial  work  in 
the  hands  of  a  good  operator  having  proved  useless,  I  decided 


128  ORIFIC1AL   SURGERY. 

upon  a  hysterectomy.  During  the  operation  the  bladder  was 
accidentally  opened,  which  served  as  a  very  serious  compli- 
cation, and  a  secondary  operation  was  necessary  to  overcome 
the  trouble  with  the  bladder.  For  weeks  and  even  months 
this  woman  vacillated  between  an  ordinary  degree  of  health 
and  the  lowest  degree  of  physical  existence.  For  days  and 
even  weeks  together  it  seemed  that  her  condition  had  only 
been  aggravated  by  the  operation.  Every  organ  in  the  body 
took  its  turn  in  becoming  disturbed,  the  stomach  absolutely 
refusing  anything  in  the  way  of  nourishment  for  days  to- 
gether. The  cystic  spasms  which  followed  were  the  most  in- 
tense I  have  ever  witnessed,  and  the  rectum  joined  in  the  gen- 
eral disturbance  by  spasmodic  contractions  which  would  con- 
tinue for  hours  at  a  time,  only  abating  when  tired  nature 
failed  completely  to  respond.  The  urine  became  suppressed, 
a  distressing  bronchitis  developed,  abscesses  in  various  parts 
of  the  body  formed,  an  exhaustive  diarrhea  supervened,  and 
everything  indicated  a  most  unfavorable  termination. 

Past  experience  told  me  that  I  should  again  do  dilatation. 
By  insisting  upon  its  doing,  consent  was  gained,  the  patient 
was  placed  under  an  anesthetic  and  thorough  dilatation  of  the 
rectum,  vagina  and  urethra  was  performed.  For  ten  days  no 
perceptible  change  followed;  in  fact,  she  seemed  to  go  lower 
in  the  scale.  At  the  end  of  the  time  usually  given  to  the  real 
convalescence  of  such  cases,  she  suddenly  grew  better  and 
continued  to  improve  rapidly  to  a  complete  recovery.  This 
I  record  as  one  of  my  most  trying  experiences  and  still  as  one 
of  my  greatest  successes.  The  lessons  this  case  taught  me 
were  to  not  hesitate  or  demur  in  repeating  the  work  if  there 
was  any  indication  for  so  doing,  and  to  never  give  up  until 
every  orificial  force  had  been  expended,  especially  where  the 
indicated  means  have  been  employed  according  to  the  laws  of 
either  of  the  three  cardinal  principles  of  orificial  philosophy. 

I  realize  how  tiresome  becomes  the  history  of  cases,  but 
as  it  is  by  the  practical  application  of  laws  that  we  determine 
their  value,  I  have  selected  these  cases.  First,  because  of 
their  gravity;  second,  because  of  the  lessons  they  each  bring. 


ORIPIG1AL   SURGERY.  129 

In  the  first  one,  but  for  the  persistent  daily  attention  the 
results  which  were  brought  about  could  not  have  been. 

In  the  second  one,  the  case  would  have  undoubtedly  been 
lost  had  not  the  blood  clot  been  removed  and  the  pinched 
nerve  fibers  released. 

In  the  third  one,  nothing  would  have  served  to  save  this 
woman  but  the  repetition  of  orificial  methods  which  ordi- 
narily would  seem  to  have  been  long  since  exhausted. 

CHAPTER  XVI. 


THE  VASOMOTOR  CENTRES. 


J.   W.   MEANS,   M.   D. 


The  arteries,  veins  and  capillaries  constitute  what  is  called 
the  circulatory  system.  Every  organ  of  the  body  is  supplied 
with  life-giving  fluid  through  a  delicately  constructed  system 
of  tubing,  just  as  every  house  in  our  great  cities  is  supplied 
with  water  through  pipes  beneath  the  surface. 

The  magnificently  constructed  pumping  station  of  the 
human  system,  located  among  the  organs  needing  the  supply 
of  vital  fluid  most,  is  a  marvel  of  mechanism  and  the  acme  of 
perfection  itself.  It  has  not  only  the  vis  a  tergo  action,  but 
the  vis  a  fronte.  This  great  system  provides  for  the  waste 
and  supply  also.  The  impurities  and  effete  matter,  when  the 
machine  is  working  normally,  pass  away  through  lungs,  kid- 
neys, and  skin,  while  the  loss  is  supplied  by  the  lacteals  along 
the  digestive  track. 

The  beautiful  and  elaborately  devised  channels  which 
carry  the  blood  through  the  body  form  a  closed  system  of 
elastic  tubes,  whose  walls  are  made  up  of  three  coats,  viz.,  ex- 
ternal, middle,  and  internal,  each  differing  from  the  other, 
but  united  in  a  way  that  adds  strength  and  elasticity  to  the 
whole.  Here,  again,  is  furnished  an  example  to  the  artisan 
who,  by  following  nature's  example,  discovers  that  a  three- 
ply  hose  is  more  durable  and  will  stand  a  greater  pressure  than 


130  ORIFICTAL   SUEGEEY. 

a  one-ply  hose,  whose  thickness  is  equal  to  the  combined 
thickness  of  the  three.  From  the  heart  to  the  capillaries,  and 
from  thence  to  the  heart  again,  the  blood  is  forced  every  twen- 
ty-eight seconds;  every  tissue  of  the  body  is  replenished  from 
this  ever-flowing  fountain.  The  countless  streamlets  that 
penetrate  the  remotest  parts  of  the  human  frame,  not  only 
supply  the  necessary  nutriment,  but  carry  off  the  effete  mat- 
ter where  it  is  consumed  and  cast  to  the  elements,  as  the  chaff 
is  divided  from  the  wheat. 

Having  briefly  pointed  out  the  perfect  system  of  tubing 
which  has  been  so  artistically  arranged  through  the  bodies 
of  all  animated  beings,  what  good  are  these,  were  it  not  for 
that  unseen,  incomprehensible  power  generated  by  the  nerve 
cells  Without  some  central  station  akin  to  an  electric-light 
plant,  where  the  electrical  current  is  generated  and  sent  hither 
and  thither  over  the  wires  to  the  various  parts  of  the  city,  to 
illuminate  the  streets,  business  houses,  and  residences  of  the 
people,  there  would  be  absolute  inaction. 

It  has  been  discovered  that  on  the  floor  of  the  fourth 
ventricle,  in  the  medulla  oblongata,  lie  the  nerve  cells  known 
as  the  vaso-motor  centers,  which  govern  the  entire  circulatory 
system,  and  from  this  point  emanates  the  power  that  sustains 
life  and  rules  the  universe.  It  controls  as  by  automatic  sim- 
plicity the  dilatation  and  contraction  of  every  blood-vessel  in 
the  body.  This  czar  of  the  kingdom  over  which  his  scepter 
extends,  rules  with  an  iron  hand  and  holds  the  key  to  the  pro- 
gressive and  retrogressive  development  of  every  organ  in  the 
human  body. 

Inflammation,  congestion  and  anemia  are  all  dependent 
upon  the  degree  of  stimulation  furnished  the  organs  affected 
by  the  central  power  in  the  fourth  ventricle.  The  delicate 
blush  of  the  maiden,  localized  as  it  were  to  the  cheeks,  has  its 
origin  in  the  intelligent  center  of  the  fourth  ventricle. 

Localized  disease  of  any  organ  is  due  to  the  interference 
of  the  nutrition  of  either  the  nerve-cells  or  the  nerve-fibers  at 
the  particular  place;  either  congestion  or  anemia  exists.  The 
cutting  of  the  sympathetic  nerve  in  -the  neck  is  followed  by 
an  increase  in  temperature  of  that  side  of  the  head,  and  great 


OREFICIAL   SUEGEBY.  131 

dilatation  of  the  arteries.  It  was  also  observed  that  stimula- 
tion of  the  superior  ganglion  of  the  sympathetic,  caused  a  fall 
in  temperature  and  contraction  of  the  vessels  in  the  side  to 
which  the  stimulus  was  applied.  Hence  we  find  that  con- 
gestion is  controlled  by  the  stimulus  furnished,  indirectly,  to 
the  constrictor  fibres  of  the  blood-vessels,  from  the  cells  or 
ganglia,  connected  with  the  central  power  in  the  fourth  ven- 
tricle. Most  of  the  brain  can  be  removed  without  diminishing 
the  arterial  tone — so  long  as  the  fibers  leading  from  the  floor 
of  the  fourth  ventricle,  or  the  central  station  itself  is  not  im- 
paired, the  blood-vessels  will  maintain  their  vital  contractility 
which  regulates  the  amount  of  blood  flowing  to  a  given  part. 
The  normality  or  abnormality  of  an  organ  depends  upon  the 
amount  of  nutrition  furnished  by  the  blood-vessels.  Disease 
is  defined  as  "that  condition  of  the  body  in  which  one  or  more 
of  its  functions  are  not  properly  performed."  Why  are  the 
various  functions  of  the  organs  disturbed?  Is  it  because  of 
microbic  action,  or  disturbed  circulation  Every  disease  has 
its  specific  germ,  according  to  the  up-to-date  bacteriologist. 
Horse  serum,  scientifically  called  antitoxine,  has  become  as 
common  as  the  equine  itself  and  it  is  advocated  today  by  a 
large  element  of  medical  practitioners  as  a  specific  for  the  cure 
of  diphtheria.  All  the  modern  physician  has  to  do  is  to  find 
the  patients,  the  bacteriologists  and  the  chemist  will  do 
the  rest. 

Confidence  is  the  basis  of  health  as  well  as  business,  and 
when  the  whole  economy  is  acting  harmoniously,  all  parts  of 
the  body  are  supplied  with  the  requisite  amount  of  blood, 
health  is  the  result.  When  one  section  of  the  country  is  block- 
aded business  is  disturbed,  the  normal  channels  of  trade  are 
interfered  with,  stagnation  follows,  bankruptcy  and  general 
loss  supervene.  So  it  is  with  the  human  body.  The  vast  net- 
work of  arteries,  veins  and  nerves  are  so  intertwined  with 
each  other  that  when  one  branch  of  the  great  system  fails  to 
perform  its  duty,  the  equilibrium  is  disturbed,  the  venal  or 
arterial  system  is  over-distended,  effete  matter  accumulates 
in  the  capillaries,  the  vasomotor  nervous  system  is  whipped  up 
to  furnish  vital  fluid  to  the  wcarv  muscles  of  the  blood-vessels. 


132  OBIFIC'IAL    SURGERY. 

until  by  sheer  exhaustion  the  parts  wherein  the  battle  of  life 
has  been  waged,  become  congested;  stagnation  and  disease  is 
the  result.  No  intelligent  individual  will  deny  the  existence 
of  microbes,  but  whether  they  are  the  cause  or  result  of  disease 
has  not  been  settled  beyond  cavil. 

Why  is  it  that  diarrheal  diseases,  and  marasmus  in  chil- 
dren, and  a  host  of  microbic  affections  are  cured  by  circum- 
cision and  rectal  dilatation?  Does  removal  of  the  prepuce 
destroy  the  germ,  or  does  the  normal  condition  following  said 
operation  result  from  the  disentanglement  of  the  nerve  fibers  ? 
Why  does  urethral  stricture  cause  gleet,  with  its  characteristic 
microbes,  and  the  removal  of  the  stricture  cure  it?  It  can  be 
accomplished  by  electricity,  dilatation,  or  urethrotomy,  neither 
of  which  can  be  termed  germicides,  but  the  germ  disappears. 

We  find  that  the  great  central  motive  power,  located  in 
the  fourth  ventricle,  has  sub-stations  known  as  ganglia,  scat- 
tered throughout  the  whole  system.  They  are  collections  of 
nerve  cells,  and  are  joined  by  delicate  bundles  of  nerve  fibers, 
from  which  branches  lead  to  the  blood-vessels  and  viscera.  They 
act  as  transformers,  reducing  the  intensity  of  the  current, 
changing  the  voltage  and  so  modifying  it,  that  the  circulation 
is  under  perfect  control.  They  also  act  as  storage  batteries, 
having  afferent  and  efferent  nerves  leading  to  and  from  the 
ganglia.  They  (the  ganglia)  can  be  excited,  the  tone  of  the 
vessels  increased,  and  pressure  raised,  either  by  direct  or  in- 
direct irritation — fear  will  blanch  the  countenance,  joy  will 
flush  the  capillaries.  There  is  no  fear  without  the  central 
ganglia  are  irritated  by  a  certain  kind  of  wave  impression. 
There  is  no  joy  without  central  irritation  due  to  a  specific 
cause. 

In  the  study  of  these  wonderful  nerve  centers  we  learn 
that  stasis  means  death,  not  alone  in  the  vasomotor  system, 
but  in  every  department  of  life.  Stagnation  means  decay.  The 
restless  ocean  purifies  itself  by  that  ceaseless  ebb  and  flow. 
The  great  river  system  of  the  world  would  become  a  stench 
and  a  menace  to  health  if  it  were  not  for  that  onward  flow 
through  gorge  and  valley,  until  lost  in  the  mother  ocean. 


SUBGERY.  133 


CHAPTER  XVII. 

THE  SYMPATHETIC  NERVOUS  SYSTEM;  OR  WHY  ORI- 
FICIAL  SURGERY  SHOULD  CURE  OR  AFFECT  MOST 
CHRONIC  DISEASES,  EXPLAINED  FROM  AN  ANA- 
TOMICAL AND  PHYSIOLOGICAL  BASIS. 


E.    P.    NOTREBE,    M.    D. 


When  discussing  orificial  surgery  we  mention  rectal  and 
genital  orifices  and  their  appendages,  not  to  the  total  exclu- 
sion of  other  orifices,  but  because  the  sympathetic  nervous 
system,  the  much  neglected  but  the  great  and  important  part 
of  the  nervous  system,  is  more  accessible  by  lower  orifices  and 
their  appendages  than  by  any  other  parts  of  the  body,  as  will 
be  seen  from  the  great  supply  and  connection  of  those  parts 
with  the  sympathetic  system.  We  should  treat  the  lower  ori- 
fices and  appendages  together  and  completely  connect  them  in 
searching  for  cause  of  disease,  because  they  are  inseparably 
connected  by  both  sympathetic  and  cerebro-spinal  nervous 
systems.  The  pudic  nerve,  which  is  of  cerebro-spinal  origin 
but  which  is  connected  with  the  sympathetic  system  in  the 
sacral  region,  gives  off  five  branches,  one  to  each  of  the  fol- 
lowing organs  and  parts :  The  largest  branch  ends  in  the  blad- 
der, the  next  in  size  goes  to  the  rectum,  the  others  go  to  penis 
or  clitoris;  the  labia  and  perineum,  and  the  uterus  and  its 
appendages.  These  parts  are  abundantly  supplied  with  sympa- 
thetic nerve  cords,  which  originate  in  the  hypogastric  plexus. 
From  this  connection  an  irritation  of  any  one  of  these  parts 
may  cause  irritation  of  any  one  or  all  of  the  others. 

To  explain  the  sympathetic  connection  of  these  parts  will 
require  a  brief  anatomical  description  of  the  sympathetic  ner- 
vous system.  First,  there  is  a  chain  of  ganglia  on  either  side 
of  the  vertebras  from  skull  to  coccyx,  called  the  lateral  chain 
of  the  sympathetic.  This  lateral  chain  is  strongly  connected 
with  the  cranial,  the  spinal  and  the  sacral  nerves.  The  second 


134  OKIFICTAL   SURGERY 

part  of  the  sympathetic  consists  of  nerve  cells  or  ganglia  aris- 
ing from  or  connected  with  the  lateral  chain,  and  from  these 
cells  or  centers  actual  nerve  cords  go  to  all  the  viscera,  to  all 
blood  vessels,  and  to  all  glands.  There  are  three  main  plexuses 
or  centers:  cervical,  solar  and  hypogastric.  The  cervical  plex- 
us includes  the  superior,  middle  and  inferior  cervical  ganglion. 
The  superior  ganglion  has  communication  with  the  four  upper 
cervical  nerves,  with  petrosal  ganglion,  with  root  and  trunk 
of  pneumogastric  nerve,  with  carotid,  cavernous  and  pharyn- 
geal  plexuses,  with  about  all  cranial  nerves,  internal  carotid 
artery  and  superior  cardiac  nerves. 

The  middle  cervical  has  connection  with  communicating 
branches  of  four,  five  and  six  cervical  nerves,  the  middle  car- 
diac and  recurrent  laryngeal.  The  inferior  cervical,  with  com- 
municating branches  of  seven  and  eight  cervical  nerves,  in- 
ferior cardiac,  and  right  and  left  pulmonary  plexuses.  The 
solar  plexus,  coeliac  axis  or  the  abdominal  brain  or  center  is 
connected  with  the  lateral  chain  by  the  three  to  four  splanch- 
nics  and  phrenic  nerve  above  and  with  lateral  chain  and  hypo- 
gastric  plexus  below.  This  center  sends  numerous  cords  to  the 
ganglia  in  stomach,  liver,  spleen,  kidneys,  pancreas  and  whole 
intestinal  tract.  The  course  of  these  nerve  strands  is  along 
blood  vessels  to  the  organs  and  tissues.  The  hypogastric  plex- 
us is  connected  with  the  lateral  chain  and  sends  cord  to  gang- 
lia in  bladder,  uterus  and  terminal  nerves  of  clitoris,  penis, 
testicles  and  rectum. 

The  physiology  of  the  sympathetic  nervous  system  is  re- 
flex action.  It  controls  the  forces  necessary  to  the  life  of  the 
body;  it  presides  over  nutrition;  controls  the  circulation  and 
glandular  secretion,  and  presides  over  the  organs  of  genera- 
tion; it  is  the  governor  of  emotion  or  rhythm,  of  all  the  tho- 
racic, abdominal  and  pelvic  viscera,  and  of  all  blood  vessels 
and  glands  wherever  located.  For  a  complete  nerve  reflex 
action,  we  must  have  a  center,  a  conducting  cord  and  a  peri- 
pheral ganglion. 

The  centers  of  the  sympathetic  are:  The  solar  plexus  or 
abdominal  brain  and  cervical  ganglion.  The  numerous  con- 


ORrFICTAL   SURGERY.  135 

ducting  cords  are  sent  out  from  centers  to  all  the  viscera,  and 
there  end  in  the  peripheral  ganglia  or  plexus  of  those  organs 
or  parts. 

The  centers  have  the  brain  power  of  reorganizing  forces, 
and  they  manage  nourishment  and  control  secretion;  they  in- 
itiate, sustain  and  prohibit  rhythm,  that  is,  the  centers  affect 
the  peripheral  ganglia  of  a  viscus,  and  the  rhythm  of  that  vis- 
cus  depends  on  the  action  of  its  ganglia;  hence  the  nutrition 
and  function  of  an  organ  are  under  the  control  of  its  terminal 
ganglion  cells. 

The  rhythm  of  the  heart,  stomach,  intestines,  lungs,  liver, 
uterus,  bladder  and  other  vital  organs,  is  due  to  influences  act- 
ing on  their  special  visceral  ganglia.  We  know  of  the  effects  of 
the  automatic  heart  ganglia.  These  ganglia  cause  the  perfect 
rhythm  of  heart,  for  when  separated  from  the  cerebrum  it  still 
has  this  peculiar  motion  or  cycle  which  we  call  rhythm.  We 
are  familiar,  too,  with  this  rhythm  in  the  digestive  tract;  the 
peristaltic  or  vermicular  action  of  the  intestines  is  due  to  the 
ganglia  situated  between  the  longitudinal  and  circular  mus- 
cular fibers  known  as  Auerbach's  plexus.  Auerbach's  plexus 
is  the  peripheral  cells  which  control  the  muscular  movements 
or  rhythm  of  the  gastro-intestinal  tract.  Meissner's  ganglia 
have  control  of  the  gastro-intestinal  secretion,  and  are  located 
just  under  the  delicate  mucous  membrane  of  the  gastro-in- 
testinal tract.  So,  special  ganglia  are  located  in  all  the  vital 
organs,  and  these  ganglia  are  almost  wholly  under  the  control 
of  the  sympathetic  nervous  system  or  centers.  The  disease  of 
a  viscus  then  is  usually  caused  by  abnormal  stimulation  or  ir- 
ritation of  its  visceral  plexus.  Irritation  may  be  direct  or  re- 
flex; it  may  be  transient  or  continuous.  When  transient,  the 
organ  may  sustain  its  function,  but  when  continuous  it  must 
become  irregular  in  motion,  nutrition  and  secretion,  and  ab- 
normal in  function.  It  is  the  continuous  irritation  that  we  as 
physicians  and  surgeons  have  most  to  deal  with,  and  when 
we  take  away  that  irritation  which  has  been  constantly  impair- 
ing the  motion,  the  secretion  and  nutrition  of  a  part,  we  free 
it  from  its  fetters  and  starvation,  and  it  will  soon  regain  what 
it  has  lost,  for  nature  will  repair  damages  if  we  only  give  it  a 


136  ORIPIGTAL  SURGERY. 

natural  chance.  We  are  warned  of  and  directed  to  irritation 
of  the  cerebro-spinal  nerve  by  special  pain;  but  the  sympa- 
thetic may  be  strongly  irritated,  and  we  may  know  nothing  of 
its  presence  unless  it  be  by  symptoms  of  disturbed  nerve  force 
or  disturbed  nutrition.  The  patient  is  not  cognizant  of  pain, 
but  seeks  the  advice  of  a  physician  on  account  of  functional 
disturbances,  such  as  palpitation  of  the  heart,  so-called  dys- 
pepsia, constipation,  liver  troubles,  skin  discoloration  and  erup- 
tions, cold  hands  and  feet,  and  various  neuroses — all  from 
terminal  irritation. 

To  trace  the  effects  of  irritation  and  reflex  action,  we  will 
commence  with  the  endometrium  of  the  uterus  or  with  a  dis- 
eased uterus.  The  uterine  irritation  affects  the  woman's  heart, 
stomach  and  intestinal  tract,  also  her  nervous  equilibrium.  It 
affects  her  heart  because  the  peripheral  ganglia  or  terminal 
nerves  in  uterus  are  irritated  and  the  impression  travels  along 
the  sympathetic  conducting  cords  to  the  hypogastric  plexus; 
from  thence,  by  two  routes:  1st,  by  lateral  chain  directly  to 
cervical  ganglia,  and  2nd,  by  cords  to  abdominal  brain  and 
thus  to  cervical  ganglia.  In  cervical  ganglia  the  forces  are 
reorganized  and  sent  down  to  heart  ganglia  by  the  three  car- 
dio-accelerator  nerves,  which  make  the  heart  go  too  fast  or  ir- 
regularly. The  stomach  is  disturbed  because  the  irritation 
goes  from  uterus  to  hypogastric  plexus,  and  from  hypogastric 
plexus  to  abdominal  brain.  The  forces  are  reorganized  and  sent 
out  by  cords  along  the  gastric  artery  to  Auerbach's  plexus 
between  muscular  layers  and  cause  contraction  or  cramp  of 
stomach  or  vomiting.  The  irritation  also  affects  Meissner's 
plexus,  just  under  mucous  membrane  of  gastro-intestinal  tract, 
and  causes  too  much  secretion,  too  little  secretion,  or  dispro- 
portionate secretion  or  indigestion.  The  woman  has  intestinal 
indigestion  because  the  irritation  goes  to  hypogastric  plexus, 
then  to  abdominal  brain,  and  forces  are  reorganized  and  sent 
out  on  superior  mesenteric  artery  to  Auerbach's  plexus,  and 
cause  too  much  contraction  or  diarrhoea,  or  too  little  contrac- 
tion or  constipation,  and  affects  also  Meissner's  plexus  and 
causes  too  much  secretion  or  diarrhoea,  to  little  or  constipa- 
tion, or  disproportionate  secretion  or  fermentation  and  colic. 


ORIFIC1AL    SURGERY.  137 

The  same  irritant  may  be  traced  to  liver  by  going  from 
uterus  to  abdominal  brain,  from  abdominal  brain  along  he- 
patic artery  to  hepatic  ganglia,  which  affects  the  rhythm  ot 
liver  and  causes  it  to  make  too  much  bile,  glycogen  and  urea ; 
too  little  bile,  glycogen  and  urea ;  or  disproportionate  bile, 
glycogen  and  urea,  in  which  the  function  of  the  liver  is  dis- 
turbed and  it  may  become  turgescent  or  hypertrophied  or  de- 
generated. The  excessive  or  disproportionate  secretions  are 
absorbed  partly  by  blood  and  show  in  discoloration  or  blotches 
of  skin.  Irritation  of  terminal  sympathetic  nerves,  if  con- 
tinued, will  carry  the  patient  through  five  different  stages ;  the 
first  is  simple  irritation,  by  its  reflex  effects  on  the  blood  sup- 
ply and  digestive  tract.  She  has  indigestion ;  from  indigestion 
comes  mal-nutrition ;  from  mal-nutrition  comes  anemia ;  and 
from  anemia  comes  neurosis  or  hysterics.  Then  the  case  comes 
to  the  physician  and  probably  not  before,  as  it  has  had  no 
special  pain. 

I  take  the  uterus  for  an  example,  simply  because  its  re- 
flexes from  disease  or  irritation  are  acknowledged;  but  the 
same  effects  can  be  caused  by  irritation  of  any  of  the  follow- 
ing parts :  Clitoris,  urethra,  bladder,  testicles,  labia  and  rec- 
tum. Clinical  experience  teaches  that  the  sympathetic  centers 
can  be  shocked  or  stimulated  more  by  the  rectum  than  by  any 
other  part.  The  most  satisfactory,  reliable  and  effectual 
means  of  resuscitation  is  by  stimulating  the  centers  per  rectum!, 
as  the  irritant  begins  in  terminal  nerves  or  ganglia  of  the  rec- 
tum and  goes  to  hypogastric  plexus,  then  by  two  routes  to 
cervical  plexus,  one  by  lateral  chain  and  the  other  through 
abdominal  brain  to  cervical  ganglia,  and  the  forces  are  there 
reorganized  and  sent  to  the  pneumogastric  nerve,  also  by 
cords  from  cervical  ganglia  to  right  and  left  pulmonary  plex- 
uses, which  stimulate  cell  action.  The  uterus  and  rectum  re- 
ceive more  conducting  cords  than  the  others,  but  all  these 
parts  are  connected  with  hypogastric  plexus,  and  as  anatomy 
has  so  strongly  connected  these  parts  with  the  central  brain 
of  the  sympathetic  system,  it  is  through  this  connection  that 
orificial  philosophy  is  applied.  By  affecting  the  central  cells 
we  affect  the  rhythm  and  secretion  of  the  viscera;  we  control 


138  ORIFICTAL   SUEGERY. 

the  circulation  and  manage  the  nutrition  of  every  organ  and 
tissue  of  the  body.  By  managing  these  fundamental  principles 
of  physiology,  orificialists  expect  to  wake  up  dormant  cells  and 
rebuild  healthy  tissue. 

This  grand  philosophy  was  conceived,  developed,  proven 
and  demonstrated  by  one  great  mind,  and  made  a  free  gift  to 
the  medical  profession  from  noble  principles.  This  mind  and 
these  principles  are  in  one  man  and  he  should  have  the  honor 
due  such  combination ;  and  that  honor  is  to  have  the  thoughts 
and  feelings  of  his  profession  that  rightly  belong  to  such  a 
progressive  wonder  as  E.  H.  Pratt,  the  hero  of  the  medical 
profession. 

In  preparing  this  article  I  made  use  freely  not  only  of 
ordinary  text  books  upon  anatomy,  but  of  special  discussions, 
demonstrations  and  descriptions  furnished  by  Dr.  F.  Byron 
Robinson,  of  Chicago,  and  have  culled  freely  from  articles  of 
Dr.  E.  H.  Pratt,  the  founder  of  the  orificial  philosophy. 


SECTION  III. 


Reflexes. 


OR1F1C1AL    SUEGEBY.  141 


CHAPTER  XVIII. 


REFLEXES. 


C.    A.    WEIRICK,    M.   D. 


Two  forces  are  continuously  exercised  in  the  human  or- 
gan, viz. :  Reproductive  and  destructive.  The  former  is  car- 
ried on  by  all  the  great  functions  of  the  body,  digestion,  res- 
piration, absorption,  circulation  and  secretion,  each  an  im- 
portant and  essential  factor  in  the  one  great  act,  nutrition, 
which  not  only  creates  the  anatomical  elements  of  a  new  be- 
ing and  continuously  repairs  or  strives  to  repair  those  of  an 
existing  organism,  but  also,  at  the  same  time,  stores  within 
these  elements  a  potential  energy  that  is  invariably  liberated 
and  set  in  action  to  reproduce  and  to  destroy.  If  the  power 
which  liberates,  renders  active  and  controls  this  energy  or 
force  be  neither  too  great  nor  too  small,  just  sufficient  to  main- 
tain a  proper  co-ordinate  organic  action,  then  in  the  body  will 
production  be  equal  to  or  in  excess  of  destruction,  thereby 
resulting  in  health  and  physical  development ;  but  if  an  insuf- 
ficient amount  of  this  latent  energy  be  changed  to  active  force 
or  work  and  heat,  then  a  slow,  insidious  degeneration  of  one 
or  more  tissue  elements  occurs,  often,  however,  preceded  by 
diminution  of  functional  activity.  If  an  amount  in  excess  of 
the  maximum  permissible  in  constructive  metabolism  be 
changed  into  kinetic  energy,  then  the  physiological  acts  and 
anatomical  structure  of  the  tissues  are  rapidly  modified  and 
altered.  Health,  then,  is  the  production  of  potential  or  re- 
serve energy,  and  the  proper  expenditure  of  the  same ;  disease 
is  a  failure  either  to  develop  this  force  or  to  expend  it  in  the 
harmonious  activity  of  all  the  elements,  tissues,  organs  and 
functions  of  the  body.  Disease  is  chronic  or  acute,  either  as 
an  insufficient  or  an  excessive  amount  of  energy  at  rest  is 
changed  to  activity.  The  development  of  this  force  and  the 
regulation  of  its  expenditure  therefore  come  within  the  prov- 


142  ORIFICIAL   SURGERY. 

ince  of  the  physician.  Those  forces  which  liberate  other  forces 
are  known  as  stimuli.  They  may  be  either  chemical,  electrical, 
mechanical,  physical,  or  that  negatively  defined  force  known 
as  vital,  which  last,  in  children  at  least,  depends  upon  heredity. 
Because  of  their  anatomical  connection  by  means  of  the  ner- 
vous system,  no  organ,  or  at  least  no  visceral  organ,  is  inde- 
pendent of  any  other;  hence,  a  natural  stimulus  applied  to 
one  directly  or  reflexly  influences  the  normal  action  of  another, 
providing  one  or  more  of  the  factors  essential  to  a  reflex  move- 
ment be  not  destroyed,  even  though  they  may  be  impaired.  It 
is,  therefore,  a  logical  deduction  that  if  the  liberating  force 
and  the  center  of  reflexion,  the  centripetal  and  centrifugal  fi- 
bers, the  three  factors  of  a  reflex  act,  be  normal  the  body  will 
be  in  a  state  of  health. 

Reflex  phenomena  depend  upon  the  condition  of  the  re- 
flex arc  and  the  character  of  the  stimuli,  most  frequently  upon 
the  transferring  center  of  the  arc,  located  either  in  the  sympa- 
thetic ganglia  or  in  the  cerebro-spinal  centers.  If  the  center, 
the  cause  of  action  or  inaction  is  central ;  if  the  stimuli,  peri- 
pheral. In  a  crude  manner  the  reflexes,  especially  those  of 
the  patellar-tendon  and  next  the  ankle  clonus,  have  been  used 
as  a  means  of  diagnosis  to  determine  well-developed  abnormal 
conditions. 

I  believe  the  time  is  not  far  distant  when  it  will  be  pos- 
sible to  determine  probably  by  the  aid  of  electricity  and  suit- 
able apparatus,  the  minimum  and  maximum  amount  of  energy 
necessary  in  the  transferring  centers  to  maintain  the  proper 
degree  of  harmony  in  organic  action.  Then  will  it  be  possible, 
by  an  earlier  diagnosis  than  it  is  now  possible  to  make,  to  pre- 
vent the  development  of  some  of  the  incurable  neurotic  and 
reflex  diseases. 

Perhaps  in  no  other  form  of  acute  disease,  especially  in 
children,  is  the  energy  of  the  reflexion  center  reduced  below 
the  minimum  of  health  or  even  exhausted  as  in  catarrhal  pneu- 
monia, one  of  the  very  serious  diseases  of  early  life.  The 
cough  often  ceases  though  there  be  no  improvement  in  the 
pathological  condition,  and  there  may  even  be  an  extension 
to  and  an  involvement  of  other  lobules  of  the  lungs.  The  in- 


ORIFIC1AL    SUEGEBY.  143 

flammation  produces  the  stimulus,  the  energy  which,  trans- 
mitted by  the  superior  and  inferior  branches  of  the  vagus,  in 
this  case  the  efferent  fibers,  to  the  cough  center,  liberates  a 
force  that  is  conveyed  by  the  efferent  fibres  in  the  nerves  of 
expiration  to  their  periphery,  resulting  in  cough.  Then,  if  the 
inflammation  is  the  stimulus  and  it  is  not  abated,  why  does 
not  the  patient  continue  to  cough,  and  by  that  means  pre- 
vent an  occlusion  of  the  smaller  bronchi  by  an  accumulation 
of  mucous?  The  potential  energy  of  the  transferring  center 
has  become  exhausted,  hence  there  is  no  power  for  the  stimu- 
lus to  discharge  through  the  efferent  fibres  of  the  reflex  arc 
to  the  contractile  tissue  involved  in  the  production  of  cough. 
This  condition  is  critical  and  often  followed  by  death. 

The  practical  lesson  to  be  drawn  from  this  experience  and 
the  results  of  its  development  is  to  sustain  the  vigor  of  the  ce- 
rebro-spinal  axis,  in  which  is  found  the  cough  center,  by  reme- 
dies acting  upon  it,  and  thereby  prevent  its  exhaustion  which 
is  so  frequently  followed  by  fatal  results.  The  statement  that 
this  may  be  done  is  corroborated  by  clinical  experience.  No 
drugs  will  be  mentioned,  as  it  would  doubtless  lead  to  a  dis- 
cussion of  the  general  treatment  of  this  form  of  pneumonia 
which  is  not  within  the  scope  of  the  paper. 

It  will  occur  to  all  that  in  many  cases  of  this  disease  the 
cough  does  not  suddenly  cease,  but  gradually  subsides  with  the 
abatement  of  the  pathological  condition ;  it  is  so  because  the 
potential  energy  of  the  reflex  cough  center  has  not  become  ex- 
hausted, either  by  the  involvement  of  a  large  area  of  lung  tis- 
sue or  by  constitutional  dyscrasia. 

Because  the  organs  are  interdependent  ( ?)  in  action,  their 
reflex  influence  should  be  considered  in  the  treatment  of  any 
one  of  them,  not  only  in  chronic,  but  in  acute  diseases. 

While  improper  food  is  doubtless  the  most  frequent  eti- 
ological  factor  in  the  production  of  diarrho?a  of  children,  yet 
there  are  not  a  few  cases  of  this  disease  that  are  caused,  not 
by  direct  irritation  of  the  digestive  tract,  but  by  reflex  influ- 
ences. The  power  of  intense  mental  conditions  to  produce 
greatly  exaggerated  peristalsis  and  involuntary  defecation  has 
been  frequently  noticed,  especially  from  fright  or  any  other 


144  ORIFIG1AL   SURGERY. 

sudden  abnormal  mental  action.  Diarrhoea  is  also  caused  in 
infants  by  changing  the  material  composing  the  garments 
worn  next  to  the  skin.  This  is  frequently  observed  when,  even 
in  the  hot  temperature  of  July  and  August,  the  clothing  worn 
next  the  skin  is  changed  from  woolen  to  cotton  goods.  I 
have  often  seen  cases  originating  from  this  cause  rapidly 
cured  by  replacing  the  cotton  by  the  woolen  garment.  It  is  a 
well  attested  fact  that  sudden  atmospheric  changes  are  pro- 
ductive of  increased  sickness,  and  frequently  increase  the  in- 
tensity, especially  in  this  latitude,  of  gastro-enteric  disorders 
during  the  month  of  September.  Unseasonable  weather — that 
is,  a  cold  summer  and  warm  winter — is  accompanied  with  an 
increased  amount  of  sickness.  This  is  not  brought  about  by 
any  direct  local  atmospherical  effect,  either  mechanical  or 
chemical,  upon  the  tissues  involved,  but  by  a  change  of  stim- 
uli, acting  on  the  peripheral  nerve  terminations,  probably  of 
the  integument,  thereby  either  diminishing  or  increasing  the 
power  of  the  inhibitory  and  motor  centers,  and  therefore 
changing  their  reflex  energy,  resulting  in  functional  and  or- 
ganic changes  of  organs  subject  to  their  influence.  It  is  not 
an  uncommon  experience  in  the  treatment  of  gastro-enteric 
diseases  of  infancy  to  be  annoyed  and  chagrined  by  frequent 
recurrence  of  the  attack  in  the  same  cases,  notwithstanding 
the  diet  and  remedies  have  been  selected  with  the  greatst  care 
and  skill.  As  impaired  glanders  secretion,  both  in  quality  and 
quantity,  and  hypera?mia  and  inflammations  may  be  caused  by 
the  reflex  influence  of  a  cold  draught  acting  on  some  por- 
tions of  the  skin,  it  is  logical  to  conclude,  especially  as  clinical 
results  verify  the  deduction,  that  intelligent  care  of  the  sur- 
face of  the  body  will  prevent  its  undue  stimulation,  and  there- 
fore protect  from  deleterious  reflex  influences  the  already 
weakened  digestive  organs,  and  prevent  frequent  relapses  of 
diarrhoea  in  children.  Diarrhoea,  again,  may  be  produced,  not 
by  direct  irritation  of  the  intestinal  canal  by  the  presence  of 
indigestible  food,  but  by  reflex  mental  influences.  The  power 
of  intense  mental  conditions  to  cause  greatly  exaggerated 
peristalsis  and  involuntary  stools  has  been  frequently  ob- 
served, especially  from  fright.  Cases  of  constipation  also 


OBIFIC1AL    SUKGEEY.  145 

may  result  from  the  same  mental  influences  that  in  others,  by 
reflex  action,  are  followed  by  diarrhoea.  Why  the  same  ex- 
citing cause  is  followed  by  an  overaction  in  one  person,  an  in- 
sufficient action  in  another,  and  a  normal  action  in  a  third,  is 
doubtless  due  to  the  different  conditions  of  the  reflex  arc  and 
the  influence  of  the  stimuli,  not  only  upon  the  motor  but  the 
inhibitory  centers.  If  the  resistance  of  the  former  were  de- 
creased and  the  latter  unchanged,  then  diarrhoea  would  fol- 
low ;  if  vice  versa,  constipation ;  but  if  they  were  both  active 
and  no  relative  change  in  their  resisting  power,  the  stimuli 
would  produce  neither  constipation  nor  diarrhoea. 

The  delicacy  of  the  mechanism  of  the  reflex  structures, 
and  the  many  changes  their  action  may  produce  in  the  charac- 
ter of  a  disease,  especially  in  diarrhoea,  teach  the  necessity  of 
careful  discrimination  in  the  selection  of  remedies  which  are 
very  similar  in  their  action.  The  many  fine  points  of  differ- 
ence between  drugs  are  therefore  not  to  be  ignored,  especially 
in  the  treatment  of  diarrhoea. 

Again  in  diarrhoea  it  will  be  noticed  that  the  indigestible 
food  in  the  intestinal  tract,  the  pathological  condition  of  the 
same  or  whatever  other  cause  may  constitute  the  stimuli,  there 
will  be  in  addition  to  the  altered  contents  of  the  intestines  only 
increased  peristalsis ;  sometimes,  however,  this  increased  ac- 
tion does  not  occur  even  though  the  stools  be  diarrhoeic  in 
character.  This  abnormal  action  represents  only  a  simple  re- 
flex response  on  the  part  of  the  muscular  coat  of  the  intestine, 
but  when  the  discharging  stimulus  is  very  strong  or  there  is 
an  excessive  degree  of  excitability  of  the  transferring  center, 
then  will  incoordinate  reflex  manifestations  exhibit  themselves 
in  the  form  of  spasms.  It  has  been  noted  by  Henry  Harts- 
home,  M.  D.,  that  more  males  than  females  die  from  cholera 
infantum.  Now,  as  the  former  is  not,  as  in  adult  life,  more 
exposed  to  the  unclemency  of  the  weather  than  the  latter,  and 
as  the  food  and  clothing  are  the  same  for  both  sexes  during 
infancy,  it  will  be  a  reasonable  deduction  to  make  that  the 
cause  of  greater  mortality  in  the  one  sex  must  be  due  to  some 
abnormal  condition  of  the  genital  organs.  These  parts  should 
be  examined.  This  is  not  stereotyped  advice  given  in  con- 


146  ORIFICIAL   SURGERY. 

nection  with  the  care  of  cholera  infantura  as  all  well  know, 
but,  because  the  rate  of  mortality  is  so  uniformly  reported 
high,  the  physician  is  warranted  in  getting  out  of  the  well 
worn  path  of  treatment  which  too  often  leads  to  death  of  the 
child.  Of  course,  it  is  far  better  to  ascertain  before  any  acute 
condition  manifests  itself  that  not  only  are  the  genital  but  all 
other  organs  free  from  conditions  that  will  impair  the  normal 
bodily  resistance.  If  such  conditions  exist,  cure  them  if  pos. 
sible  before  they  weaken  the  organism  by  their  reflex  influ- 
ence, and  thereby  act  as  a  predisposing  cause  of  disease. 

I  think,  as  a  rule,  doctors  are  inclined  to  ignore  the  small 
abnormal  conditions  of  the  body  which  act  as  stimuli  for  the 
reason  that  they  do  not  produce  acute  disease  or  because  they 
forget  that  a  weak  stimulus  existing  for  a  short  time  may  not 
cause  a  reflex  act;  but  if  it  be  continued  may  produce  this 
act.  Had  nature  intended  to  protect  the  body  only  against 
large  sources  of  irritation,  it  would  have  made  the  nerves  large 
like  the  muscular  system ;  but  many  of  them  are  microscopical 
and  ramify  every  part  of  the  body,  being  especially  numerous  in 
the  more  exposed  parts  of  the  body.  They  are  so  very  suscept- 
ible to  stimuli  that  one  of  their  functions,  no  doubt,  is  to  early 
give  warning  of  an  assault,  no  matter  how  trivial,  on  the  vital 
force.  A  small  source  of  irritation  continuously  exerted  de- 
creases its  power  of  resistance.  For  example,  a  very  small 
foreign  substance  in  the  eye  may,  if  not  removed,  cause  de- 
struction of  its  fellow;  the  presence  of  some  indigestible  sub- 
stance in  the  intestinal  tract  may  produce  convulsions  and 
sometimes  death.  Still  another  familiar  example  may  be 
given,  viz. :  A  small  piece  of  secundines  will  produce  hemor- 
rhage, not  because  it  is  large  enough  to  prevent  contraction 
but  because  of  reflex  influence.  Then,  if  such  a  weak  stimuli 
will  produce  serious  functional  derangements  in  adult  life,  it 
is  not  strange  that  it  will  have  a  deleterious  influence  in  child 
life;  and  while  the  harm  may  not  be  manifested  at  once,  still 
the  loss  of  recuperative  power  so  often  given  as  a  reason  for 
not  curing  patients  of  acute  disease  may  be  due  to  the  long 
continued  action  of  a  stimuli  so  weak  that  were  it  continued 
but  a  short  time  it  would  make  no  perceptible  influence  on  the 


ORIFICTAL    SURGERY.  147 

patient's  health.  It  is  to  lessen  the  severity  of  acute  diseases 
and  prevent  the  development  of  those  that  are  chronic  in 
character,  that  the  child  should  be  examined  for  abnormal 
conditions  at  birth. 

Probably  the  most  common  of  these  in  male  children  is 
the  adherent  and  redundant  foreskin.  The  following  cases  are 
given  to  show  some  of  the  different  reflex  conditions  pro- 
duced by  it. 

The  first  case  showed  symptoms  of  an  imperfect  gastric 
digestion  during  the  first  few  months  after  its  birth,  which 
continued  until  cured  at  the  age  of  six  years.  During  the  sec- 
ond summer  of  its  existence  it  had  frequent  acute  attacks  of 
gastro-intestinal  catarrh.  These  attacks  recurred  so  frequently 
that  the  child  was  taken  on  a  boat  to  northern  Michigan.  Some 
little  improvement  was  wrought  by  the  change  of  climate,  but 
it  was  late  in  the  fall  before  it  became  fairly  out  of  danger  of 
these  serious  acute  manifestations  of  the  disease.  The  stom- 
ach remained  weak,  imperfectly  doing  its  work,  aggravated  by 
a  diet  not  very  carefully  regulated,  both  in  regard  to  quality 
and  quantity.  It  was  also  influenced  by  changes  of  temper- 
ature. Several  physicians,  myself  among  the  number,  treated 
the  patient  without  producing  any  marked  improvement.  He 
was  for  a  time  under  the  professional  charge  of  a  specialist 
for  diseases  of  the  digestive  organs,  without  benefit.  Of  course 
acute  exacerbations  subsided  with  or  without  medicine.  When 
he  was  six  years  old  I  was  asked  to  prescribe  for  enuresis,  that 
troubled  him  day  as  well  as  night.  Thinking  there  might  be 
some  local  cause  of  this  annoying  trouble,  I  examined  the  geni- 
tal organ,  and  found  the  foreskin  adherent  to  one  side  of  the 
glans  penis.  This  was  corrected  in  less  than  five  minutes  with 
my  fingers.  He  had  no  further  trouble  in  retaining  the  urine, 
and  he  made  marked  improvement  from  that  time.  One  year 
after  his  mother  reported  no  more  trouble  with  the  digestive 
organs. 

It  is  not  claimed,  of  course,  that  every  case  of  enuresis, 
any  more  than  every  case  of  indigestion,  is  caused  by  the  con- 
dition described  in  the  above  case. 


148  ORIFIC1AL   SUBGEEY. 

I  was  asked  to  examine  a  male  child  eighteen  months  old, 
an  idiot.  The  parents  were  very  intelligent.  It  had  been  de- 
livered by  the  aid  of  instruments.  No  evidence  of  injury  could 
be  found.  The  mother,  wiser  than  some  doctors,  in  this  case  at 
least,  made  a  comparative  examination  between  her  child  and 
the  male  child  of  a  friend.  The  foreskins  were  different.  The 
mother  reasoned  that  as  her  child  was  ill  and  the  friend's  well, 
if  either  foreskin  was  wrong  it  must  be  that  of  her  boy.  The 
child  was  circumcised  and  the  adhesion  between  the  glans 
penis  and  the  foreskin  broken  up.  The  child  was  well  in  two 
months.  There  was  marked  mental  improvement  during  the 
first  week  following  the  operation. 

The  following  are  cases  cured  by  operation  on  the  fore- 
skin, reported  by  Sayre:  Child  five  years  old,  knees  flexed  at 
angle  of  45  degrees,  paralysis  of  extensors,  pulse  weak.  Ten- 
otomy  had  been  advised,  but  not  performed.  Two  weeks  after 
the  operation  the  child  walked  without  aid,  and  finally  made  a 
complete  recovery. 

Double  talipes  equinovarus  paralytica  in  child  aged  three 
years.  Had  been  under  treatment  between  two  and  three 
years  in  a  public  institution  of  New  York.  Greatly  improved 
in  two  weeks  after  operation. 

Paralysis  of  lower  extremities,  prolapsus  of  rectum  and 
constipation.  Operation  June  1,  could  stand  alone  June  4,  and 
complete  recovery  at  the  end  of  twelve  days. 

Partial  atrophy  of  optic  nerve  in  man  aged  34  years,  eye 
trouble  of  eight  years'  duration,  can  only  read  large  print  and 
then  but  few  minutes  together.  Operation  restored  general 
health  in  one  month  and  enabled  the  patient  to  read  a  page 
of  small  print  without  any  unpleasant  results. 

Dr.  Sayre  also  reports  cases  benefited  by  correcting  trou- 
bles of  the  clitoris.  One  child  whom  he  treated  was  eight 
years  old  and  had  never  been  able  to  walk.  Two  months  after 
operation  she  walked  unaided  across  three  rooms. 

These  cases  are  given  to  call  attention  to  the  fact  that  an 
irritation  in  the  same  part  of  the  body  may  produce  various 
reflex  diseases  in  different  individuals.  It  should  also  be  re- 
membered that  the  stimuli  that  results  in  great  functional  dis- 


OREPIC'IAL    SURGERY.  149 

turbances  in  a  single  organ  in  each  case,  may  in  others  diffuse 
its  force  to  many  organs,  thereby  slightly,  in  a  short  time,  im- 
pairing them  all,  with  no  very  clear  manifestations  of  disease 
in  any  one ;  but  by  undermining  the  recuperative  power  the  in- 
dividual is  rendered  especially  susceptible  to  any  exciting 
cause  of  disease  and  ultimately  some  chronic  ailment  is  in- 
sidiously developed. 

I  will  give  an  example  to  corroborate  the  last  statement. 
A  young  lady  about  eighteen  years  of  age,  had  for  many  years 
of  her  life  been  subject  to  severe  attacks  of  headache,  the  at- 
tacks gradually  increasing  in  frequency.  She  was  pale,  list- 
less and  tired,  with  a  poor  appetite.  The  menses  were  regular 
and  normal.  She  had  had  several  acute  diseases,  one  of  which 
was  typhoid  fever.  She  had  not  since  a  child  been  considered 
a  very  strong  girl  by  her  parents.  Of  course,  she  had  sought 
relief  from  physicians  and  taken  much  medicine  without  any 
apparent  benefit.  I  was  no  more  successful  with  drugs  than 
those  who  had  previously  prescribed  for  her.  Finally  I  did 
what  should  have  been  done  when  she  was  a  child,  examined 
the  clitoris,  and  found  the  hood  adherent.  The  adhesions  were 
loosened  and  the  patient  gradually  gained  strength  and  re- 
covered from  the  headaches.  No  drug,  no  matter  how  care- 
fully selected,  would  cure  such  a  case  and  it  was  unwise,  un- 
scientific to  administer  drugs  to  her.  And  yet  I  have  no  doubt 
that  many  chronic  cases  called  nervous  prostration,  general 
debility  or  some  other  of  the  indefinite  terms  that  physicians 
have  taught  the  laity  to  expect  as  expressing  something  sci- 
entific, are  due  to  a  reflex  irritation  perhaps  no  greater  than 
the  one  in  the  case  just  described,  and  which  may  be  pro- 
duced by  congenital  deformities. 

These  cases  have  been  given  to  show  not  only  that  an  ab- 
normal stimulus  may  cause  reflex  disease,  but  also  that  the 
same  stimulus  produces  different  diseases  in  different  individ- 
uals. Notice  in  these  cases  that  the  irritation  caused  by  the 
foreskin  resulted  in  chronic  impairment  of  the  stomach  di- 
gestion in  one  subject;  idiocy  in  another;  in  a  third  paralysis 
of  the  extensors  of  the  leg;  a  fourth,  talipes  equinus;  a  fifth, 
paralysis  of  the  lower  extremities,  constipation  and  protrusion 


150  ORIFICIAL 


of  the  rectum;  and  in  the  sixth,  after  many  years,  serious  im- 
pairment of  vision.  In  other  cases  with  a  less  degree  of  irri- 
tation, or  a  greater  amount  of  constitutional  strength  pos- 
sessed by  the  patient,  there  will  be  produced  less  marked 
symptoms  of  disease,  but  none  the  less  surely  will  the  various 
functions  of  the  child  organism  be  impaired  and  predisposed 
to  disease  conditions,  which  are  entirely  too  common  and  fatal 
in  childhood.  Often  nature  corrects  the  trouble  ;if  it  does  not 
the  adult  is  invariably  an  invalid;  but  even  when  nature  re- 
moves the  cause  of  irritation  serious  harm  has  been  done  to 
the  child.  It  is  not  creditable  to  medicine  and  surgery  that 
there  are  thousands  of  people  in  all  countries  where  medicine 
is  taught  suffering  from  chronic  disease.  These  very  often 
may  be  traced  back  to  childhood,  and  to  causes  that  were  re- 
movable at  that  age.  Dr.  Pratt  has  discovered  and  taught,  and 
his  teaching  has  been  corroborated  by  all  who  have  made 
clinical  use  of  it,  that  the  lower  part  of  the  rectum  is  abund- 
antly supplied  with  nerves,  which  act  as  afferent  fibers  to  a 
reflex  arc,  and  that  abnormal  conditions  of  this  part  of  the 
bowel  are  productive  of  many  reflex  disorders.  He  has  found 
that  dilatation  of  the  sphincter  ani  is  a  powerful  means  of  re- 
suscitation, and  that  it  is  the  most  reliable  method  known  for 
starting  respiration  in  still-born  children. 

Since  the  originator  of  this  method  introduced  it  to  the 
profession  it  has  come  into  general  use  as  a  means  of  resus- 
citation. 

A  regular  physician  writes  as  follows:  "The  methods  of 
resuscitation  usually  employed  are  open  to  various  objections. 
They  all  require  time  which  is  the  all-important  element  in 
these  cases.  Some  of  them  compel  the  use  of  unseemly  and  dis- 
agreeable measures,  others  of  more  or  less  cumbersome  and 
inconvenient  means,  and  all  distract  the  physician's  attention 
from  the  mother,  who  at  this  time  peculiarly  and  by  every 
right  is  entitled  to  that  care  and  consideraton  which  only  the 
closest  and  most  constant  attention  can  secure  to  her.  These 
are  the  general  objections  —  not  to  specify  the  many  inhuman 
and  grotesque  impositions,  such  as  spanking  the  baby,  alter- 
nate boiling  and  freezing  with  hot  and  cold  baths,  mouth  to 


ORIFICIAL    SURGERY.  151 

mouth  insufflation,  artificial  respiration,  and  the  various  other 
scientific  indignities  which  are  daily  being  perpetrated  upon 
helpless  innocence." 

Of  course  dilatation  of  these  sphincters  must  affect  the 
respiration  by  means  of  reflex  influence. 

If  relaxing  the  anal  muscles  to  an  extreme  degree  assists 
respiration,  then  their  abnormal  contraction  which  may  be 
caused  by  the  presence  of  a  local  irritant,  will  reflexingly  hin- 
der respiration  or  compel  the  respiratory  centers  to  expend  an 
undue  amount  of  energy  to  regulate  these  processes.  In  either 
case  disease  must  result,  the  vital  force  be  diminished  and  a 
chronic  disease  slowly  developed  or  an  acute  one  rendered  less 
amenable  to  treatment. 

It  is  not  my  purpose  to  discuss  rectal  pathology  in  con- 
nection with  reflexes,  but  I  do  wish  to  assert  that  it  is  the  causfc 
of  many  functional  derangements  which  are  frequently  fol- 
lowed by  organic  changes.  Patients  do  not  understand  why 
a  slight  irritation  of  the  glans  penis,  the  clitoris,  the  rectum  or 
the  nares  will  produce  trouble  remote  from  its  direct  action, 
nor  why  the  ill  effects  are  more  pronounced  than  if  a  greater 
stimulus  were  applied  to  the  nerve  nearer  its  central  termina- 
tion. The  first  is  understood  by  a  knowledge  of  the  fact  that 
a  stimulus  may  be  so  weak  and  of  such  short  duration  that 
there  will  be  no  discharge  of  a  reflex  act,  but  if  it  be  continued 
it  will  produce  the  act.  The  second  because  stimulation  of  the 
peripheral  end  of  the  efferent  nerve  more  readily  and  thor- 
oughly causes  the  discharge  of  a  reflex  act  than  stimulation  in 
its  course.  For  example,  a  slight  continued  tickling  of  the 
skin  over  the  knee  will  in  many  individuals  cause  incon- 
trollable  and  hysterical  laughter,  while  stimulus  applied  to  the 
main  nerve  from  which  this  region  is  supplied  causes  local 
pain  only. 

One  of  the  common  derangements  of  early  childhood  is 
constipation.  The  laxatives  of  the  regular  school,  the  home- 
opathic remedies  and  a  diet  carefully  selected  from  the  many 
foods  at  the  command  of  the  physician  all  fail  too  often  to 
cure  this  condition.  Very  frequently  after  other  means  have 
been  faithfully  tried  the  trouble  has  been  overcome  by  dilata- 


i- 


152'  ORIFIC1AL  SURGERY. 

tion  of  the  anal  sphincters.  The  same  cause  that  will  in  one 
subject  produce  constipation  will  in  another  cause  diarrhoea.  I 
have  seen  the  former  cured  by  curing  an  anal  fissure;  in  an- 
other case  the  latter  cured  by  removing  the  same  cause.  Re- 
cently a  case  came  under  observation  who  had  had  diarrhoea 
for  a  year.  The  patient  had  from  two  to  a  dozen  loose  stools 
in  twenty-four  hours.  Colicky  pains  preceded  defecation  with 
rumbling  of  gas  in  the  abdomen.  There  were  no  sharp  nor  se- 
vere pains  in  the  anus,  only  a  slight  smarting  or  burning  sen- 
sation— nothing  that  resembled  the  usual  description  of  the 
pains  incident  to  a  fissure.  But  nevertheless  a  large  one  ex- 
isted. Local  anaesthesia  was  produced  by  a  solution  of  cocaine, 
then  95  per  cent,  carbolic  acid  applied  to  the  fissure ;  the  stools 
became  normal  in  one  week  after  the  treatment.  It  should  not 
seem  strange  to  the  members  of  our  school  of  medicine  that  dif- 
ferent conditions,  or  rather  opposite  manifestations  of  the  same 
conditions,  respond  to  the  same  remedy.  It  may  be  explained 
by  the  difference  in  the  discharging  power  of  the  center  of  the 
reflex  arc. 

While  calling  attention  in  a  general  way  to  the  important 
influence  that  stimuli  may  exert  in  a  reflex  manner  on  remote 
organs  of  the  body,  it  is  in  nowise  intended  that  other  causes  of 
disease  should  be  ignored,  for  it  would  be  foolish  to  treat  a 
disease  due  to  central  conditions  alone  as  a  reflex  disorder.  I 
believe,  however,  that  many  chronic  pathological  conditions 
which  seem  to  be  primary  are  due  to  long  continued  impair- 
ment of  important  processes  of  the  body  due  to  reflex  influ- 
ences that  permit  the  development  of  these  diseases  which  be- 
come independent  and  do  not  disappear  after  the  exciting 
cause  is  removed.  The  importance  of  a  thorough  examination 
of  a  child  can  not  be  overestimated.  All  abnormal  stimuli 
should  be  corrected  if  the  danger  incident  to  child  life  be  re- 
duced to  a  minimum  and  the  increase  in  the  great  army  of 
chronic  sufferers  be  stopped. 


ORIFICIAL    SURGERY.  153 


CHAPTER  XIX. 


REFLEX  NEUROSES. 


A.   W.    REDDISH,    M.   D. 


First,  what  is  a  neurosis?  It  is  a  functional  nervous  dis- 
ease, or  a  derangement  of  the  function  or  office  of  a  nerve.  In 
the  auditory  nerve  it  is  manifested  by  a  singing  and  roaring 
in  the  ears;  in  the  optic  nerve  by  the  blurring  of  vision  and 
specks  before  the  eyes ;  in  the  olfactory  nerve  by  exalted  or  de- 
ranged olfaction;  in  the  sensory  nerves  by  formication  and 
pain;  in  the  vaso-motor  nerve  by  the  spasms  of  the  arterioles 
and  disturbed  circulation;  and  in  the  motor  nerves  by  irregu- 
lar and  spasmodic  movements. 

What  is  a  reflex  action?  As  most  of  the  movements  and 
operations  of  the  body  are  conceded  to  be  produced  by  re- 
flex actions,  it  is  well  to  understand  this  subject.  Reflex  ac- 
tions are  involuntary,  and  are  of  two  kinds — reflex  actions  in 
health  and  reflex  actions  in  disease.  The  former  are  always 
regular,  and  have  a  purpose  in  view,  while  the  latter  are 
irregular  and  purposeless.  It  is  of  the  latter  that  I  intend  to 
write.  So,  after  a  few  preliminary  words  on  reflex  actions  in 
health,  I  will  proceed  with  the  subject  of  this  paper. 

If  a  stimulus  is  applied  to  the  extremities  of  an  afferent 
nerve,  the  impression  is  carried  along  that  nerve  to  a  reflex 
center,  then  back  over  an  efferent  nerve  to,  it  may  be,  a  re- 
mote part  of  the  body,  and  an  action  produced  differing  in 
kind  from  the  stimulus,  but  corresponding  with  the  function 
of  the  efferent  nerves  so  affected.  Well  known  instances  of 
this  action  are  legion,  and  have  been  observed  from  remote 
times.  For  instance:  Tickle  the  sole  of  the  foot  and  the  leg 
is  withdrawn ;  or  let  a  strong  light  fall  upon  the  retina  and  the 
pupil  contracts;  place  a  strong  acid  on  the  tip  of  the  tongue 
and  muscles  of  the  face  are  immediately  set  in  motion. 

There  is  one  other  point :  If  a  slight  stimulus  be  applied 
to  the  right  foot,  the  leg  draws  up;  if  this  stimulus  be  in- 


154  ORIFIGiAL   SURGERY. 

creased,  both  legs  will  draw  up;  and  if  it  be  still  further  in- 
tensified, it  will  be  reflected  along  motor  nerves  that  arise  from 
points  higher  up  in  the  spinal  cord,  until  all  the  muscles  of 
the  body  are  thrown  in  motion.  Observe  the  application  of 
this  law  to  reflexes  in  disease  further  along  in  the  paper. 

Reflex  action  in  disease  is  caused  by  irritation  of  the  peri- 
pheral extremity  of  an  afferent  nerve.  This  nerve  may  be 
either  cerebro-spinal  or  sympathetic.  This  irritation  passes  to 
a  reflex  centre,  and  is  then  reflected  over  an  efferent  nerve, 
when  a  functional  derangement  takes  place.  This  reflex  action 
or  functional  disturbance  it  must  be  understood,  is  not  the  re- 
sult of  chance,  but  is  governed  by  an  inflexible  law.  Every  ir- 
ritation must  produce  its  own  reflex  action.  Gastric  irrita- 
tion produces  frontal  headache.  Renal  irritation  produces  oc- 
cipital headaches.  Worms  and  other  intestinal  irritations  in 
children  produce  spasms.  Slight  irritations  only  produce 
twitchings,  and  adults  in  whom  reflex  actions  are  considerably 
diminished,  similar  irritations  produce  no  result  whatever.  In 
this  case  the  sympathetic  or  afferent  nerve,  and  the  cerebro- 
spinal  the  efferent  nerve.  Among  other  well  known  examples 
may  be  mentioned  spasms  from  teething,  epilepsy  from  sexual 
irritations,  tetanus  and  trismus  from  penetrating  wounds  in- 
volving the  cerebro-spinal  nerves.  The  fact  that  this  is  very 
common  in  the  horse  and  does  not  occur  at  all  among  other 
animals,  verifies  the  facts  that  modifying  causes  exist,  and  in- 
hibition which  must  always  be  taken  into  consideration.  Dr. 
Stevens  whom  Dr.  Ranney  quotes  on  "Lectures  on  Nervous 
Diseases, ' '  proves  quite  conclusively  that  chorea  may  generally 
be  cured  by  correcting  visual  defects,  refractive  or  muscular. 
Other  well-known  and  frequently  verified  examples  are  in- 
continence of  urine  from  phymosis,  and  nausea,  and  vomiting 
from  irritation  of  the  internal  os  uteri.  This  is  most  frequent- 
ly observed  during  pregnancy,  where  flexions  and  versions  ex- 
is  to  such  an  extent  that  the  nerves  of  the  internal  os  are 
pressed  upon  and  severely  irritated.  Aside  from  pregnancy, 
various  uterine  diseases  will  produce  these  identical  symptoms, 
such  as  prolapsus  and  inflammations,  flexions  and  versions. 


ORIFIC'IAL  SURGERY. 


CHAPTER  XX. 


ORIFICIAL  REFLEXES  CLINICALLY  ILLUSTRATED. 


S.   G.    A.    BROWN,   M.   D. 


The  term  reflex  is  applied  to  an  action  which  consists  in 
the  refiexation  by  an  efferent  nerve  of  an  impression  conveyed 
to  a  nervous  center  by  an  afferent  nerve.  All  reflex  or  excito- 
motory  movements  are  regarded  as  being  executed  independ- 
ent of  consciousness.  That  we  may  better  understand  this  re- 
flex excitation  and  appreciate  its  intrinsic  worth  in  the  diag- 
nosis and  prognoses  of  disease,  I  will  cite  a  few  cases  which 
have  come  under  my  own  observation. 

Case  1.  Miss  J.,  age  30,  of  good  family  history,  had  been 
an  invalid  for  fifteen  years.  The  first  symptom  noticed  was  a 
slight  limping,  a  lameness  of  the  right  hip  upon  moving.  This 
was  soon  succeeded  by  pain  from  which  she  suffered  more  or 
less  until  the  event  of  her  recovery.  At  times  the  pain  was  ex- 
cruciating, unbearable,  especially  after  retiring  for  the  night, 
often  compelling  the  patient  to  get  out  of  bed.  The  pain  was 
at  times  sharp,  at  other  times  a  dull  ache,  extending  from  the 
right  hip,  laterally  and  posterially,  downward  toward  the 
knee,  somewhat  to  the  outside  of  the  sciatic  nerve.  There  ex- 
isted, at  the  time  of  my  examination,  an  atrophic  condition  of 
the  large  gluteal  muscle  and  the  tensor  vaginae  femoris.  Her 
health  appeared  to  be  good,  excepting,  of  course,  this  trouble. 
When  she  came  under  my  care  she  was  unable  to  walk  to  my 
office,  a  distance  of  two  blocks.  She  had  been  under  the  care 
of  all  the  prominent  local  allopathic  physicians,  yet  was  con- 
tinually growing  worse.  During  the  first  six  months  she  was 
under  my  treatment  I  prescribed  such  remedies  as  I  believed 
to  be  homeopathically  applicable  to  the  case,  also  using  galvan- 
ism, and  hot  sitz-baths  on  retiring  at  night.  The  result  was  a 
slight  alleviation  of  the  pain  and  transient  amelioration  of 
other  symptoms.  Upon  closer  examination  I  was  informed 


156  OEIFIC1AL   SURGEfcY. 

that  at  each  menstrual  nisus  she  suffered  untold  agony ;  also, 
between  the  periods  was  inconvenienced  with  a  thick,  whitish 
leucorrhea.  I  insisted  upon  a  thorough  examination  and  found 
a  stenosed  condition  of  the  cervix,  a  fissure  of  the  rectum,  and 
an  extensive  catarrhal  condition  of  both  these  mucous  tracts. 
My  treatment  was  now  directed  toward  these  parts,  relieving 
the  catarrhal  affection,  dilating  the  cervix,  healing  the  fissure, 
and  using  the  galvanic  current  a  few  days  before  each  cata- 
menial  period,  for  several  months,  applying  the  cathode  to  the 
hypo-gastrium  and  the  anode  in  the  uterine  canal.  Relief  was 
immediate,  recovery  quick  and  permanent;  the  result,  more 
than  I  had  expected.  Six  months  have  now  elapsed,  during 
which  she  has  had  no  pain,  and  can  walk  with  the  greatest 
ease  and  freedom. 

Case  2.  Mrs.  S.,  age  35,  was  delivered  of  her  fourth  child 
January,  1895.  Her  physician,  in  order  to  hasten  delivery, 
used  manual  force.  From  the  hour  of  the  child's  birth  she  be- 
gan to  decline,  at  times  suffering  very  severely.  I  was  called 
to  see  her  April  16th ;  found  her  very  restless,  nervous,  suffer- 
ing much  pain  in  the  region  of  the  uterus,  together  with  great 
dyspnrea  and  diffused  pain  in  the  chest.  Upon  examination  I 
found  a  thin,  brownish,  watery  discharge  from  the  vagina,  ex- 
coriating the  external  genitals  and  inner  surfaces  of  the  thighs, 
and  a  lacerated  cervix  sensitive  and  inflamed.  She  informed 
me  this  condition  had  existed  three  months,  or  from  the  date 
of  her  confinement.  Also  that  her  former  physician  had  found 
it  necessary  to  keep  her  continuously  under  the  influence  of 
opiates  in  order  to  relieve  the  great  pain  and  severe  dyspno?a. 
I  relieved  her  of  what  morphia  tablets  she  had  by  placing  them 
in  my  satchel,  and  prescribed  arsenicum,  3x,  a  powder  every 
two  hours,  promising  to  call  the  next  day.  That  night  I  was 
awakened  from  my  pleasant  dreams  of  the  life  of  a  country 
doctor,  and  was  hurried,  more  asleep  than  awake,  to  her  bed- 
side, to  find  her  in  a  state  of  high  nervous  excitement.  She 
declared  she  was  dying  and  implored  immediate  succor.  Her 
husband  demanded  that  I  restore  the  stolen  morphia  tablets. 
This  I  kindly  did  by  substituting  arsenicum  tablets,  30th  tri- 
turation.  Marked  improvement  began  within  fifteen  minutes, 


ORIFICTAL    SURGERY.  157 

and  at  the  end  of  an  hour  I  was  enabled  to  return  home.  On 
my  arrival  next  day  I  found  a  marked  amelioration  of  all 
symptoms,  she  having  passed  a  quiet  night.  Improvement  con- 
tinued for  the  space  of  three  weeks,  when  the  excoriating  dis- 
charge once  more  made  its  formidable  appearance.  Receiving 
the  consent  of  both  husband  and  wife,  I  operated  upon  the  lac- 
erated cervix,  cleansing  it  first  with  absorbent  cotten,  removing 
the  plug  of  mucus  in  cervical  canal  by  means  of  a  curette,  and 
then  performing  the  Emmet  operation.  The  result  was  most 
flattering.  Improvement  began  at  once,  and  she  made  an  un- 
eventful recovery,  all  her  chest  and  heart  troubles  disappear- 
ing immediately  and  simultaneously. 

Case  3.  Miss  L.,  age  19,  of  a  romantic,  poetic,  bilious  tem- 
perament, otherwise  apparently  healthy;  would  at  various  in- 
tervals, from  intuition,  an  overloaded  colon,  or  otherwise, 
launch  off  into  paroxysms  of  poetic  ecstasy,  during  which  pa- 
per, ink  and  temper  reigned  supreme,  the  whole  culminating 
one  Sabbath  afternoon  in  a  violent  outburst  of  acute  mania. 
I  was  hastily  summoned  and  found  her  yelling  lustily  that 
this  "world  is  all  a  dream,"  and  frantically  endeavoring  to 
"kick  the  devil  off  the  earth,"  while  her  father  and  two  other 
gentlemen  were  endeavoring  to  hold  her  in  the  "old  arm- 
chair," and  trying  to  pacify  her  by  holding  her  mouth  shut. 
Belladonna  tincture  certainly  deserves  much  credit  for  hav- 
ing come  to  our  aid  in  this  most  trying  moment,  but  she  was 
never  entirely  relieved  until  I  loosened  the  much-adherent 
hood  of  her  clitoris.  This  cured  her  of  her  poetic  fancies  and 
brought  her  to  her  senses  within  ten  minutes.  It  has  now  been 
a  year  and  there  has  been  no  signs  of  a  recurrence.  Might 
there  not  be  others  who,  having  this  great  desire  to  launch  off 
into  the  sea  of  poetry  and  the  beautiful,  could  likewise  be 
benefited  by  some  similar  simple  operation? 

Case  4.  Mr.  II.,  age  40,  bachelor,  has  had  annually  re- 
curring attacks  of  hay  fever.  During  these  attacks  he  suffered 
greatly  with  nasal  coryza,  lachrymation,  profuse  perspiration, 
sternutation,  etc.  I  used  all  our  prominent  hay  fever  reme- 
dies, allium  cepa,  sabadilla,  (natrum)  muriaticum  and  naph- 
thalin,  the  only  result  being  a  slight  alleviation  of  the  suffer- 


158  ORIFICIAL    SURGERY. 

ing,  to  recur  next  year.  He  informed  me  that  during  these  at- 
tacks he  could  breathe  with  the  greatest  difficulty  only,  and 
that  his  nostrils  felt  raw  and  were  sensitive  to  touch.  Upon 
examination  I  found  an  almost  complete  stenosis  of  the  nos- 
trils, due  to  the  inferior  turbinated  bones  on  both  sides  being 
swollen.  Cocaine  gave  temporary  relief,  but  the  cure  was  not 
complete  until  applications  of  the  compound  tincture  of  ben- 
zoin were  made.  The  recovery  was  rapid,  and  he  has  now 
passed  two  summers  entirely  relieved  of  his  old  enemy. 

There  is  one  point  in  this  latter  case  to  which  I  desire  to 
call  your  especial  attention,  namely,  that  the  reflex  irritation 
here  was  found  in  one  of  the  upper  openings  of  the  body  and 
not  in  the  lower.  Dr.  Pratt  says :  ' '  There  is  one  predisposing 
cause  for  all  forms  of  chronic  diseases,  and  that  is  a  nerve 
waste  occasioned  by  orificial  irritation  at  the  lower  openings 
of  the  body."  The  above  case,  as  Dr.  Bryson,  of  Pittsburgh, 
remarked,  was  ''cured  under  Dr.  Pratt 's  theory,  but  not  un- 
der Dr.  Pratt 's  practice."  If  the  orificial  theory  be  true  at 
all  it  must  be  true  in  its  entirely.  In  my  last  paper  before  you 
I  cited  a  case  of  asthma  which  was  entirely  cured  by  the  ad- 
ministration of  arsenic,  and  simple  dilatation  of  the  rectal 
sphincters.  Today,  did  time  and  space  permit,  I  could  cite  a 
case  of  asthma  which  yielded  to  no  treatment  until  hypodermic 
injections  of  ergot  and  the  internal  administration  of  baryta 
jod,  reduced  a  hypertrophied  tonsil  to  its  former  natural  size 
and  volume.  The  relief  was  then  immediate  and  permanent. 

Surely  there  is  more  in  this  world  than  we  wot  of,  and 
the  prophet  has  truly  said  our  bodies  are  "fearfully  and 
wonderfully  made."  I  believe  all  chronic  diseases  to  be  aggra- 
vated by  some  reflex  irritation,  and  they  cannot  be  perma- 
nently cured  until  the  cause  is  removed.  Many  cases  of  dys- 
pepsia have  their  seat  of  aggragation  in  the  rectum.  Many 
epileptics  could  undoubtedly  be  greatly  benefited  and  probably 
cured  were  more  attention  given  to  their  generative  organs. 
Nasal  polypi  have  caused  asthma,  and  a  bean  in  the  ear  has 
produced  convulsions.  If  we  desire  to  become  physicians  in 
reality,  relieving  patients  more  promptly  and  thereby  gaining 
more  credit  for  ourselves,  we  must  study  our  patients  more  and 


OBIPIC1AL    SURGEEY.  159 

their  diseases  less;  we  must  first  find  out  the  cause  and  then 
remove  it;  we  must  investigate  all  cases  a  posteriori  and  not 
a  priori;  we  must  be  what  we  pretend  to  be,  endowed  with 
wisdom. 

We  are  aware,  when  a  nerve  is  excited,  it  conveys  the  im- 
pression to  the  nerve-cell  in  the  cerebral  cortex  or  gray  sur- 
face of  the  brain.  This  stimulates  neighboring  cells  like  a  wave 
circle,  so  that  the  disturbance  spreads  on  all  sides,  as  all  brain 
substances  which  are  contiguous  and  adjacent  to  the  primary 
irritated  nerve-cell  decompose  and  transmute  their  energy  in- 
to other  places  and  into  other  forms.  Thus  we  can  easily  see 
why  an  adherent  prepuce  may  produce  convulsions,  and  why 
a  collection  of  smegma  may  be  a  causal  factor  in  the  pro- 
duction of  acne. 

Further,  physiology  has  plainly  instructed  us  that  the 
cerebral  cortex  receives  its  stimuli  from  both  the  external  and 
the  internal  nerves  of  the  organism,  i.  e.,  it  receives  impres- 
sions from  both  the  cerebro-spinal  and  the  sympathetic  ner- 
vous systems.  Max  Nordau,  he  of  degenerate  fame,  has  aptly 
expressed  it  thus:  "The  cerebral  cortex  receives  its  stimuli, 
not  only  from  the  external  nerves,  but  also  from  the  interior 
of  the  organism,  from  the  nerves  of  separate  organs,  and  the 
nerve  centers  of  the  spinal  cord  and  the  sympathetic  system. 
Every  excitement  in  these  centers  affects  the  brain-cells,  and 
arouses  in  them  more  or  less  distinct  presentations,  which  are 
necess'arily  related  to  the  activity  of  the  centers  from  which 
the  stimulus  proceeds.  .  .  If  we,  from  some  cause,  maybe 
^n  affection  of  the  heart  or  lungs,  cannot  breathe  freely,  we 
have  not  only  a  hunger  for  air,  but  also  accompanying  ideas  of 
an  uneasy  nature,  presentiments  of  unknown  dangers,  melan- 
choly memories,  etc."  Thus  it  can  readily  be  seen  that  many 
chronic  affections  are  produced  or  aggravated  by  reflex  irri- 
tation ;  that  the  irritation  of  an  organ  begins  at  its  mouth : 
that  remote  organs  may  become  involved,  reflexly ;  and  that  if 
we  would  be  successful  in  eradicating  these  chronic  troubles, 
we  must  remove  the  cause,  applying  our  healing  hands  to 
the  source. 


160  ORIFIC1AL    SURGERY. 

CHAPTER  XXI. 

THE    NECESSITY    OF    THE    CONSIDERATION    OP    RE- 
FLEXES IN  MAKING  DIAGNOSES. 


P.    S.    REPLOGLE,   M.   D. 


I  find  in  the  practice  of  medicine  we  are  too  apt  to  take 
things  as  they  appear,  not  as  tihey  really  are.  Our  patients 
complain  of  pain  of  certain  organs  of  the  body  and  we  at  once 
jump  to  the  conclusion  that  all  we  need  to  do  is  to  prescribe 
the  indicated  remedy  for  that  organ  and  our  patient  is  cured. 
But  how  often  we  are  mistaken  and  find  things  are  not  what 
they  seem. 

We  find  there  is  something  lacking.  A  patient  improves 
for  awhile  and  we  begin  to  flatter  ourselves  upon  our  wonder- 
ful skill,  when  lo,  we  are  greeted  with  the  information,  "Doc- 
tor, my  old  troubles  have  returned."  Now,  when  we  reflect  a 
few  moments,  in  the  light  of  orificial  surgery  we  find  we  are 
at  fault.  In  making  our  diagnosis  we  have  not  recognized  re- 
flex action  or  the  real  source  of  the  disease.  We  have  simply 
treated  effect,  not  cause,  and  I  hold  no  man  can  treat  chronic 
diseases  without  recognizing  the  Philosophy  of  Orificial 
Surgery. 

To  suggest  to  you  the  importance  of  recognizing  reflex 
action  in  making  our  diagnosis  and  treating  especially  chronic 
diseases,  I  will  mention  a  few  cases  in  practice : 

Mr.  S.,  aged  22,  a  university  student,  rushed  into  our  of- 
fice saying,  "Doctor,  I  have  heart  disease,  give  m'e  something, 
quick."  We  quieted  the  young  man,  examined  the  heart  care- 
fully, but  could  find  no  organic  heart  disease.  On  account  of 
the  great  anxiety,  redness  of  face,  full  rapid  pulse,  etc.,  we 
prescribed  aconite.  In  two  or  three  weeks  our  patient  returned 
with  the  same  symptoms,  stating  that  the  medicine  helped  him 
at  first  but  he  was  as  bad  as  ever.  The  spells  were  about  the 
same  as  they  had  been  for  two  years.  Something  must  be 


ORIFICIAL    SUEGERY.  161 

done  or  he  had  to  give  up  his  studies  and  leave  the  University. 
His  father  was  a  physician  and  expected  me  to  care  for  his 
boy  while  in  our  town.  I  was  desperate,  but  orificial  surgery 
came  to  my  rescue.  I  told  the  young  man  I  must  examine  his 
rectum.  He  insisted  there  was  nothing  wrong  with  him  there 
and  never  had  been.  I  insisted  there  was,  and  succeeded  in 
examining  the  rectum.  I  found  an  irritable  rectum  with  a 
few  pockets.  I  inserted  a  blunt  hook  into  one  of  them,  caus- 
ing him  to  faint.  I  sent  him  to  his  home  with  a  written  diag- 
nosis to  his  father,  which  impressed  him  so  favorably  that  he 
telegraphed  for  me  to  come  and  operate.  I  performed  the 
American.  In  due  time  the  son  returned  to  school  and  was 
able  to  carry  two  extra  studies,  and  was  one  of  the  brightest 
students  in  the  University  of  Illinois.  I  desire,  however,  to 
say  by  way  of  parenthesis,  once  afterward  he  came  to  my  of- 
fice having  the  same  symptoms  as  formerly.  I  gave  him  a  few 
doses  of  aconite,  which  helped  him  immediately  and  perma- 
nently. It  is  now  two  years  since  the  operation,  and  with  this 
exception  there  has  been  no  sign  of  the  old  troubles. 

I  will  describe  an  additional  case : 

A  man,  afflicted  with  indigestion,  vomiting,  etc.,  for  years. 
At  one  time  was  unable  to  retain  anything  in  his  stomach  for 
about  twenty  days.  Had  pain  and  especially  in  the  pyloric 
orifice.  The  case  was  diagnosed  catarrhal  gastritis,  obstruc- 
tion of  the  pyloris,  cancer,  etc.,  and  prescribed  for  by  the  most 
eminent  physicians  of  this  country.  The  vomiting  was  almost 
continual  and  the  patient  was  quite  weak  and  emaciated.  In 
this  condition  the  American  operation  was  performed.  Silk 
sutures  were  used  and  the  four  days  they  remained  the  irrita- 
tion of  the  stomach  was  fearful.  He  could  not  retain  a  table- 
spoonful  of  water  or  nourishment.  The  sutures  were  removed 
in  the  evening,  the  patient  turned  over  in  bed  and  attempted 
to  vomit.  He  failed.  He  took  nourishment  four  times  during 
the  night  and  about  four  times  a  day  for  three  or  four  weeks, 
when  he  regained  his  former  weight  and  strength. 

These  are  only  two  cases  selected  from  a  large  experience 
in  orificial  work,  but  they,  like  all  the  others,  illustrate  the 
importance  of  recognizing  orificial  reflexes. 


SECTION  IV. 


The  Technique 
of  Orificial  Surgery. 


ORIFIC1AL   SURGERY.  165 


CHAPTER  XXII. 


THE  TECHNIQUE  OF  ORIFICIAL  SURGERY. 


C.    S.    ELDRIDGE,   M.   D. 


To  have  a  general  knowledge  of  certain  kinds  of  surgical 
work  which  a  surgeon  desires  to  do  without  first  having  seen 
such  work  done,  imposes  a  task  in  operating  less  easy  than  is 
the  case  where  one  has  been  an  assistant  or  a  deeply  inter- 
ested looker-on.  An  operation  upon  the  cadaver  is  beset  with 
no  dangers;  the  heart-beat  and  respiration  are  not  present  as 
possible  sources  of  anxiety  to  the  thoughtful,  conscientious 
operator.  He  proceeds  with  all  deliberation  and  without  in- 
terruption from  the  flow  of  venous  or  arterial  blood.  He  has 
no  concern  as  to  the  consequences  of  shock,  and  proceeds  sim- 
ply as  a  mechanic. 

In  the  field  of  amputations,  and  resection  in  laparotomies, 
as  well  as  most  other  surgical  procedures,  so  much  has  been 
written  and  so  many  excellent  cuts  presented  that  little  is  to 
be  desired  in  the  way  of  further  information.  Concerning  ori- 
ficial  work,  however,  comparatively  little  information  has  been 
afforded  the  profession.  I  have  been  flooded  with  letters  from 
brother  practitioners  in  all  sections  asking  for  instruction  as 
to  the  methods  of  procedure  in  orificial  work;  and  as  all  do 
not  buy  a  work  on  orificial  surgery,  I  have  deemed  it  best  to 
answer  through  our  best  medium,  the  Journal  of  Orificial 
Surgery. 

In  order  to  determine  whether  orificial  troubles  exist  or 
not,  a  few  instruments  are  absolutely  necessary.  I  consider  the 
following  indispensable:  bivalve  rectal  speculum,  blunt  hook, 
vaginal  speculum  (Sim's  or  any  good  bivalve),  uterine  sound, 
a  bottle  of  lubricant  and  a  gynecological  chair  or  table  for 
examination.  The  position  on  the  left  side  with  knees  well 
drawn  up  is  the  one  I  like  best  for  examination  in  either  sex. 
With  patient  in  this  position  the  rectum,  vagina,  uterus  and 


166  ORIFIG1AL   SURGERY. 

prostate  can  all  be  examined.  The  initial  step  in  an  exami- 
nation should  be  to  pass  the  finger,  well  lubricated,  into  the 
rectum  or  vagina.  The  state  of  the  sphincters  can  in  this  way 
be  determined,  and,  according  to  sex,  the  uterus  and  its  ap- 
pendages, or  prostate,  gauged  as  to  size,  tenderness,  etc.  A 
little  experience  soon  renders  the  digital  touch  of  great  diag- 
nostic value.  Man's  prostate  is  to  him  what  woman's  uterus 
is  to  her;  therefore  any  disorder  of  these  structures  should  be 
carefully  noted,  as  diseases  of  them  are  prevalent  the  world 
over.  Here  conjoined  manipulation  establishes  its  claims  to 
superior  excellence  in  determining  the  morbid  conditions,  if 
any  exist,  of  the  uterine  appendages. 

Examinations  of  the  nose,  ears  and  mouth  come  under  the 
head  of  orificial  examinations ;  but  as  the  troubles  most  preva- 
lent are  found  in  the  rectum,  uterus,  vagina  and  urethra,  I 
shall  only  refer  to  those  in  this  article,  which  I  wish  to  make 
brief. 

If  a  patient  comes  into  your  office  away  below  par  in  the 
matter  of  health,  and  the  usual  routine  of  questions  generally 
employed,  examinations  and  past  forms  of  treatment  have 
failed  to  clear  up  and  benefit  the  case,  examine  the  dependent 
outlets  of  the  body;  ask  if  chronic  diarrhoea  or  constipation 
exist;  ask  for  and  insist  upon  an  examination  of  the  rectum 
and  urethra^  the  uterus  or  prostate.  To  do  this  is  to  find,  in  a 
great  majority  of  cases,  chronic  in  type,  piles,  pockets,  papillae, 
carunculae,  granulation  of  the  endometrium,  one  or  all  as  ex- 
citing causes.  I  proceed  with  these  cases  as  described,  and 
usually  find  the  bulk  of  them  are  susceptible  of  not  only  bene- 
fit but  radical  cure.  Now,  if  I  find  these  orificial  troubles  to 
exist  and  straightway  remove  them  by  surgical  methods  and 
my  patients  get  well,  there  can  be  no  mistake  in  diagnosis. 

The  rectum  is  seldom  examined.  Why  should  we  not 
examine  this  part  of  the  economy?  Simply  because  it  is  the 
channel  through  which  defecation  is  effected,  should  it  escape 
inspection  and  treatment?  Certainly  not.  Many  physicians, 
however,  give  it  the  right  of  way  and  leave  it  to  take  care  of 
itself.  There  is  not  an  organ  or  a  structure  of  the  male  or 
female  economy  that  should  be  allowed  an  immunity  from  ex- 


ORIFICTAL    SUEGEEY.  167 

animation.  A  little  tact  and  firmness  almost  always  will  en- 
able the  physician  to  push  his  examination  as  far  as  he  de- 
sires and  as  far  as  is  necessary  in  these  cases  to  arrive  at  cor- 
rect conclusions. 

There  is  a  great  difference  in  patient  so  far  as  suscepti- 
bility to  pain  is  concerned.  Some  are  so  profoundly  influenced 
by  the  introduction  of  a  speculum  into  the  rectum  that  syn- 
cope follows.  I  have  never  failed  to  find,  in  such  cases,  a 
diseased  state  of  the  last  inch  of  the  bowel.  Some  are  greatly 
distressed  by  even  the  gentle  introduction  of  the  lubricated 
finger.  To  attempt  the  use  of  a  speculum  in  such  a  case  would 
be  a  folly  and  a  failure.  It  is  a  rule  with  me,  in  these  cases, 
to  advise  an  examination  during  a  state  of  anaesthesia,  of 
course  being  prepared  to  do  any  operating  the  revelations  of 
the  case  suggest. 

A  rectum  too  sensitive  to  stand  examinations  without 
ether  I  always  find  the  seat  of  morbid  structural  changes.  A 
tight  sphincter  is  an  index  of  trouble  in  the  pile-bearing  inch 
of  the  rectum.  I  find  this  the  case  without  exception. 

To  not  locate  orificial  trouble  is  to  make  but  poor  head- 
way in  diagnosticating  chronic  ailments.  By  it  reflex  causes 
are  found  and  pathological  phases  determined.  After  the  rec- 
tal speculum  is  introduced,  it  should  be  opened  slowly  by  gent- 
ly approximating  its  handles,  care  being  observed  to  go  only 
so  far  with  dilatation  as  patient  is  willing  to  tolerate.  To  go 
beyond  this  point  will  inflict  excruciating  pain  and  probably 
lose  you  a  patient.  The  set-screw  maintains  dilatation  at  any 
point  desired.  When  the  speculum  is  introduced  and  blades 
separated,  the  blunt  hook  should  be  employed  for  the  detection 
of  pockets  and  papillae,  as  these  are  pests  most  frequently 
found,  creating  appalling  nerve  waste,  which  we  see  revealed 
in  the  endless  array  of  chronic  maladies. 

A  pocket  is  a  solution  of  the  continuity  of  the  mucous 
membrane  of  the  rectum,  and  may  be  likened  to  a  pocket  in  a 
slipper  case  such  as  hangs  upon  closet  doors.  They  are  easily 
detected  by  the  blunt  hook,  which,  if  held  at  the  right  angle, 
easily  slips  into  them.  A  papilla  is  a  teat  of  elevation  of  tis- 
sue on  the  surface  of  the  rectal  mucous  membrane;  and  if  a 


168  ORIFIGlAL   SUKGEEY. 

person  ever  had  one  and  at  the  same  time  maintained  a  maxi- 
mum standard  of  health,  I  would  like  to  know  it.  No  such 
case  has  ever  come  under  my  observation. 

External  piles  it  requires  no  skill  to  detect.  When  these 
are  found,  pockets  are  usually  found  which  antedate  them.  I 
treat  all  cases  of  external  piles  with  a  clamp  of  my  own  in- 
vention, which  cuts  and  clamps  simultaneously.  By  its  use, 
enormous  external  haemorrhoids  are  removed  with  the  loss  of 
less  than  a  tablespoonful  of  blood.  Straight  needles  two  and 
a  half  inches  long  are  passed  behind  the  clamp,  armed  with 
carbolized  silk.  After  this  the  clamp  is  removed,  when  the 
severed  edges  of  tissue  are  coapted  by  tying  the  suture  silk 
already  in  place.  Before  tying,  the  tissues  included  in  the  ser- 
rated portion  of  the  clamp  should  be  trimmed  off  close  to,  but 
not  beyond,  the  clamped  tissue. 

In  rectal  operations,  the  lithotomy  position  I  like  best. 
The  mode  of  operation  for  removing  pockets  and  papillae  is 
as  follows:  Patient  in  dorsal  decubitis,  thoroughly  anesthet- 
ized. Just  here  examine  pelvic  viscera  by  digital  touch  or 
conjoined  manipulation  to  avoid  injuring  the  uterus,  ovaries  or 
prostate  if  these  organs  are  unusually  large  or  in  a  state  of 
chronic  inflammation,  as  by  the  use  of  the  rectal  speculum 
about  to  follow,  great  damage  and  aggravation  of  already  ex- 
isting troubles  might  ensue  and  the  operator  be  charged  with 
ignorance,  negligence,  and  making  his  patient  worse  instead  of 
better.  Now  gently  introduce  the  bivalve  rectal  speculum,  well 
soaped,  the  rectum  first  having  been  treated  the  same  way; 
and  by  compressing  its  handles  dilate  to  the  extent  of  separat- 
ing the  blades  of  the  instrument  an  inch  or  even  a  little  more. 
At  this  juncture,  have  an  assistant  take  charge  of  the  handles 
of  the  speculum  so  that  the  blunt  hook  can  be  employed  by 
the  operator  for  the  detection  of  pockets.  When  one  is  found 
into  which  the  blunt  hook  passes,  a  long-handled  tenaculum  is 
used  and  passed  from  the  top  to  the  bottom  of  the  pocket,  en- 
gaging only  mucous  membrane.  Now  a  pair  of  double  curved 
scissors  are  used  to  cut  the  pocket  out  from  top  to  bottom. 
Only  slight  haemorrhage  follows  this  procedure.  If  a  papilla 
is  encountered,  lay  hold  of  it  with  tissue  forceps  and  with  scis- 


ORIFIC1AL    SURGERY.  169 

sors  cut  it  off  level  with  the  mucous  membrane.  Any  internal 
haemorrhoids  that  are  found  should  be  seized  with  a  small 
clamp  (I  have  devised  one  for  crushing  internal  piles)  so  as 
to  prevent  bleeding;  and  when  well  pinched  they  should  be 
removed  with  the  double  curved  scissors.  The  curved  variety 
is  employed  to  avoid  cutting  contiguous  tissue.  I  have  the 
greatest  satisfaction  in  using  the  little  clamp  mentioned  as  it 
so  thoroughly  controls  haemorrhage. 

When  the  rectum  is  rid  of  piles,  pockets,  papillae,  one  or 
all,  look  for  blind  fistula  and  if  such  trouble  is  found,  make  the 
opening  co-extensive  with  the  cavity  beyond  it  and  curette 
thoroughly.  To  touch  the  fistulous  tract,  after  curetting,  with 
carbolic  acid,  one  to  ten  or  twenty,  would  not  be  amiss. 

As  the  internal  sphincter  is  presided  over  by  the  sympa- 
thetic, over-distension  of  it  should  be  gradually,  carefully,  yet 
completely  accomplished.  Respiration  is  sometimes  profound- 
ly affected  by  too  vigorous  dilatation.  When  this  phenome- 
non is  observed,  stop  the  dilatation  or  modify  it  according  to 
the  necessities  of  the  case;  never,  however,  leave  a  patient 
after  having  done  work  upon  the  pile-bearing  inch  of  the  rec- 
tum without  doing  as  a  finishing  feature — as  an  indispensable 
auxiliary — complete  dilatation,  carried  usually  in  adults  to 
the  point  of  closing  the  handles  of  the  speculum.  This  es- 
sential part  of  orificial  work  frees  the  sympathetic  of  its  bur- 
den and  allows  the  capillaries  immediately  to  fill.  The  truth  of 
this  is  easily  demonstrated;  take  a  patient  worn  down  with 
nerve  waste  to  the  extent  of  habitually  having  cold 
hands  and  feet.  When  such  a  patient  is  put  on 
the  operating  table,  the  extremities  are  found  to  be 
cold.  After  complete  dilatation,  examine  and  they 
will  invariably  be  found  warm.  What  does  it?  Indisputably 
an  improved  capillary  circulation.  After  operations  upon  the 
rectum,  there  is  in  a  small  percentage  of  cases,  some  pain  at- 
tended by  a  smarting  which  compresses  wrung  out  of  hot 
water  to  which  Pond's  Extract  in  small  quantities  has  been 
added,  will  very  soon  stop.  Occasionally  where  much  rectal 
work  has  been  necessary,  an  example  of  powerful  reflex  action 
is  shown  by  inability  to  operate  the  vesical  sphincter;  reten- 


170  ORIFIGTAL    SURGERY. 

tion  of  urine  is  temporarily  established  and  sometimes  for  a 
day  or  more  a  catheter  must  be  called  into  requisition.  Such 
things  as  these  impress  me  greatly  in  studying  reflexes. 

Whenever  a  patient  stops  breathing  under  ether,  don't 
get  excited,  elevate  the  patient's  heels,  essay  artificial  respira- 
tion and  other  irrational  maneuvers.  Simply  pass  a  rectal 
speculum  and  quickly  open  it  a  little;  it  will  astonish  and 
please  the  most  incredulous  to  see  the  response  of  the  respira- 
tory center  and  start  breathing  instantaneously. 

The  shock  or  impetus  given  the  sympathetic  distribution 
of  the  internal  sphincter  will  put  things  in  motion  as  expedi- 
tiously  as  the  great  Columbian  Exposition  machinery  was 
when  President  Cleveland  touched  the  magic  button.  Only  a 
trustworthy  assistant  should  be  allowed  to  administer  the  an- 
aesthetic during  orificial  work.  Beside  him,  it  is  necessary  to 
have  two  other  assistants,  one  upon  either  side  of  the  operator, 
to  pass  instruments,  hold  speculum,  tenaculum,  blunt  hook, 
clamp,  control  irrigation,  etc.  A  hard  table  and  a  good  light 
are  desiderata  to  be  appreciated.  I  use  a  Kelly  cushion  to  con- 
duct water  and  debris  into  a  portable  washbowl  placed  at  the 
operating  end  of  the  table.  Thorough  curetting  and  ample 
stretching  quickly  disposes  of  that  painful  trouble  known  as 
fissure  of  the  anus. 

Orificial  work  does  not  mean  rectal  work  alone;  there- 
fore, every  meatus  that  is  too  small,  whether  congenital  or  not, 
should  be  enlarged  cutting  from  above  downward,  a  grooved 
director  being  used  to  guide  the  knife.  The  prostatic  urethra 
is  a  locality  prone  to  various  forms  of  difficulty  that  cause 
much  suffering,  mental  and  physical,  in  the  male  portion  of 
the  community;  therefore,  a  sound  well  soaped  should  be 
passed  to  ensnare  secretions.  When  mucus  is  found  adhered 
to  the  instrument,  it  shows  a  lesion  of  the  mucous  membrane 
usually  about  the  opening  of  the  ejaculatory  ducts,  possibly  at 
some  other  point  likely  in  the  veru  montanum.  Sounds  sub- 
sequently passed  once  in  a  week  or  ten  days  usually  tone  up 
such  cases  for  me.  The  female  urethra  should  be  examined  for 
carunculae  and  if  any  are  found,  they  should  be  cut  out  or  re- 


ORIFIC1AL    SURGERY.  171 

moved  by  the  Paquelin  cautery.  To  do  the  rectal  work  and 
leave  carunculae  would  insure  a  fiasco. 

In  vaginismus,  I  use  the  rectal  speculum  and  thoroughly 
dilate  the  vagina  with  it,  removing  before  I  stop,  every  portion 
of  the  inflamed  hymenic  fringe.  Ragged  mucous  membrane  is 
treated  the  same.  If  there  be  any  undue  sexual  excitement  so 
as  to  make  it  a  feature,  I  look  for  the  clitoris  which  is  liable 
to  be  found  hidden  almost  out  of  sight  by  a  tight  and  overlap- 
ping hood.  I  remove  enough  tissue  at  the  commissure  to  free 
the  organ,  this  being  virtually  a  female  circumcision.  Remov- 
ing smegma  completes  the  treatment  here  needed. 

The  ablation  of  the  clitoris  is  as  a  rule  barbarous,  inhu- 
man and  unscientific.  Free  it,  and  good  results  will  follow; 
modification  and  not  annihilation  is  best.  If  a  cervix  be  found 
with  a  cicatrix,  dilate  thoroughly  and  remove  it.  Let  me  ad- 
vise— nay  more,  warn — you,  however,  against  dilating  a  uterus 
that  has  an  old  scar  in  its  cervix,  which  scar  is  responsible  for 
reflex  disorders.  To  dilate  and  leave  the  cicatrix  behind  as 
an  enlivened  element  of  danger,  will  not  add  to  that  surgeon's 
glory  who  does  it. 


CHAPTER  XXIII. 


SURGICAL  JUDGMENT. 


CURTIS  M.   BEEBE,  M.  D. 


The  first  principle  to  be  observed  in  the  practice  of  ori- 
ficial  surgery,  as  in  all  surgical  work,  is  thorough  surgical 
cleanliness.  Infection  of  a  wound  from  an  unclean  atmosphere 
or  improperly  cleansed  instruments  or  hands  not  made  per- 
fectly aseptic,  will  be  the  greatest  barrier  to  success  to  those 
not  trained  in  hospital  service. 

The  second  principle  to  be  observed  is  the  selection  of  the 
case.  Not  all  cases  of  chronic  disease,  and  very  few  cases  of 
acute  disease,  are  amenable  to  orificial  treatment.  For  ex- 
ample, cases  of  pulmonary  or  intestinal  tuberculosis  are  not 


172  OEIFIC1AL   SURGERY. 

favorable  subjects  for  orifieial  surgery  after  they  have  de- 
veloped a  temperature  above  the  normal.  Pus  cases  are  not 
proper  orifieial  cases  until  the  pus  has  been  evacuated  and 
thorough  drainage  established.  Then,  repair  may  often  be 
hastened  by  attention  to  orifieial  details. 

Third,  each  case  should  be  diagnosed  as  accurately  as  is 
possible,  in  order  to  state  positively  to  the  patient  and  friends 
the  length  of  time  of  treatment.  Some  cases  require  only  one 
month,  while  others  demand  one  or  more  years.  The  prognosis 
is  of  the  utmost  importance  to  our  patient. 

Fourth,  all  of  the  sources  of  irritation  should  be  diligent- 
ly sought  at  the  first  examination,  and  each  one  should  re- 
ceive attention  according  to  its  importance. 

Two  cases  of  uterine  fibroid  presented  themselves  for 
treatment  at  about  the  same  time  and  for  nearly  the  same 
symptoms.  Both  were  subperitoneal.  One  was  as  large  as  an 
orange;  the  other  filled  the  pelvic  basin.  Both  suffered  from 
headache,  which  was  described  as  excruciating  and  unbear- 
able. Both  had  obstinate  constipation  and  backache.  Both 
had  grown  from  posterior  uterine  wall,  and  rested  heavily 
upon  the  rectum.  Both  had  large  hemorrhoids,  as  would  be 
expected  from  the  direct  pressure.  The  American  operation, 
with  thorough  flushing  of  the  colon,  repeated  several  times, 
relieved  the  headache  and  backache  almost  completely.  The 
tumors  are  both  diminishing  slowly  in  size  under  the  galvanic 
current  and  the  iodide  of  calcarea,  2x  trit.  The  large  tumor 
is  now  about  the  size  of  an  orange,  and  the  smaller  one  not 
larger  than  an  egg.  Each  patient  has  had  about  twenty  elec- 
trical treatments.  The  American  operation  gave  immediate 
and  permanent  relief  of  the  symptoms  most  complained  of, 
and  has  undoubtedly  assisted  in  the  reduction  of  the  tumors. 

Mrs.  S.,  from  South  Carolina,  visiting  in  Chicago,  present- 
ed the  following  history:  Age  45,  anjemic,  could  see  through 
her  ears,  emaciated,  tenderness  over  liver,  skin  wrinkled  and 
yellow,  suffered  from  headache  and  neuralgia.  Neuralgia  un- 
doubtedly malarial  in  origin,  as  she  has  been  a  victim  of  chills 
and  quinine.  Had  passed  blood  from  rectum  with  stools  for 
more  than  a  year.  The  American  operation,  followed  by  dila- 


ORIFIC1AL    SURGERY.  173 

tation  with  rectal  plugs  after  three  or  four  weeks,  left  her 
prostrated,  and  I  sent  her  home  with  some  misgivings.  It  is 
now  one  year  since  the  operation.  She  has  gained  43  pounds, 
and  says  she  is  perfectly  well. 

It  has  been  my  observation  that  cases  of  anaemia  require 
from  three  to  six  months  to  furnish  them  rich  blood.  Having 
several  cases  of  anasmia  under  treatment,  most  of  them  passing 
the  food  more  or  less  undigested,  I  had  an  opportunity  of  test- 
ing homoeopathic  treatment  with  and  without  orificial  aid, 
some  patients  refusing  orificial  treatment.  Gale,  phos.,  aresni- 
cum  and  other  remedies  were  employed  in  the  cases  not  op- 
erated upon,  but  almost  every  case  became  discouraged  and 
disappeared  from  observation  before  the  cure  was  completed. 
The  orificial  cases  went  through  the  uterine  packing,  or  Ameri- 
can operation,  or  both,  and  after  a  few  weeks  began  to  gain 
both  in  color  and  weight. 

Of  many  cases  of  constipation,  only  a  very  few  have  re- 
sisted orificial  treatment.  One  case  of  chronic  pyelitis  was 
cured  after  six  months'  faithful  prescribing,  after  the  orificial 
work  had  put  new  life  into  a  wreck  of  a  human  being.  Pour 
cases  of  sciatica  have  been  thoroughly  cured  by  persistent  and 
repeated  applications  of  orificial  philosophy. 

The  result  of  much  labor  and  study  has  convinced  me  that 
my  failures  have  not  been  from  any  defect  in  the  philosophy, 
but  from  my  imperfect  or  unwise  application  of  its  principles. 


CHAPTER  XXIV. 


ORIFICIAL   SURGERY— ITS  DANGERS  AND  POSSIBILI- 
TIES—A PREVENTIVE  MEASURE. 


E.   H.   PRATT,   M.   D. 


I  feel  more  than  ever  the  importance  of  laying  especial 
stress  upon  the  fact  that  orificial  surgery  is  an  edged  tool, 
capable  not  only  of  infinite  good,  but  also  of  infinite  harm. 
That  it  is  not  merely  local  work,  but  has  a  profound  effect 


174  ORIFIC'IAL   SURGERY. 

upon  the  capillary  circulation  of  the  entire  body;  and  that  it 
is  not  to  be  undertaken  with  impunity,  or  to  be  carried  out 
without  a  proper  degree  of  caution. 

Submitting  patients  to  the  shock  of  a  thorough  operation 
in  orificial  work  at  the  office  and  permitting  them  to  walk, 
ride  or  go  about  their  business  as  before,  is  hazardous  in  the 
extreme.  Several  deaths  have  already  been  caused  by  this 
practice  and  more  will  be  caused  unless  it  is  stopped. 

Galen  claimed  that  any  power  that  instantaneously  affect- 
ed the  entire  circulation  of  the  body  was  a  dangerous  one  and 
must  be  handled  with  extreme  care,  and  his  observations  were 
undoubtedly  correct.  Orificial  surgery  is  one  of  these  meas- 
ures. As  quick  as  thought,  dilatation  of  the  lower  openings 
of  the  body  lifts  the  flood  gates  of  the  circulation  and  flushes 
the  capillaries  universally.  The  conditions  must  be  right,  the 
subsequent  care  adequate  to  the  severity  of  the  measure,  in 
order  to  employ  the  process  with  safety. 

This  calls  to  mind  the  fact  that,  whereas,  in  all  cases  of 
chronic  disease,  there  is  orificial  irritation,  we  must  consider 
how  this  irritation  can  be  taken  away  and  the  undue  tension 
of  the  sphincters  relieved  without  danger  to  the  patient.  Some 
constitutions  are  strong  and  can  bear  this  sudden  shaking  up 
with  perfect  safety  and  magical  benefit.  Others  are  so  sensi- 
tive as  to  be  unable  to  tolerate  the  shock  with  safety. 

How  can  we  handle  these  more  delicate  cases  and  ac- 
complish our  purpose  of  relieving  the  irritation  and  correct- 
ing the  stenosis  of  these  parts;  knowing  its  profound  effect 
upon  the  whole  system,  at  the  same  time,  always  do  good  and 
never  harm 

A  blow  that  a  professional  pugilist  would  stand  with  im- 
punity would  probably  kill  men  who  were  unused  to  such  se- 
vere concussions.  There  is  such  a  thing  as  becoming  inured  to 
shocks  and  that  fact  can  be  employed  to  advantage  in  ori- 
ficial methods.  In  your  weak,  delicate  subjects  it  would  be 
well  to  begin  with  a  gentle  dilatation  of  the  rectum,  with  the 
occasional  passing  of  a  sound,  and  employing  these  methods  at 
long  or  short  intervals  according  to  the  necessities  of  the  case. 


ORIFICIAL    SURGERY.  175 

and  subjecting  the  patient  between  times  to  other  means  of 
flushing  the  capillaries,  such  as  massage,  spinal  fomentations, 
static  electricity,  abdominal  respiration,  etc. 

After  the  patient  has  been  carried  by  these  milder  meas- 
ures to  a  point  where  they  fail  to  any  further  improve  his 
condition,  by  that  time  his  system  has  become  sufficiently  ac- 
customed to  the  flushing  of  the  capillaries  occasioned  by  the 
methods  employed,  that  he  is  ready  for  whatever  surgical 
work  may  be  necessary  to  put  the  parts  in  proper  condition. 

The  anaesthetic  may  then  be  employed  and  even  the  se- 
verest forms  of  orificial  methods,  not  only  with  safety,  but 
with  the  happiest  of  results.  Too  much  stress  cannot  be  laid 
upon  this  thought  for,  to  the  casual  observer  unfamiliar  with 
the  effect  of  orificial  work,  it  seems  such  a  simple  matter  to 
do  a  little  pruning  and  dilatation  under  an  anaesthetic,  that 
they  can  scarcely  believe  the  effect  upon  the  entire  system 
will  be  so  profound  as  it  really  is. 

After  a  few  patients  have  been  killed  and  paralyzed  and 
rendered  insane  by  the  careless  handling  of  the  work,  the  op- 
erators will  acquire  a  more  profound  respect  for  it;  but  all 
these  unhappy  experiences  can  be  saved  if  they  will  only  take 
warning  from  those  who  have  already  had  experience,  and 
handle  the  work  with  the  proper  degree  of  caution. 

By  thus  preparing  the  patient  for  the  final  work  by  re- 
peated flushings  of  the  capillaries,  by  dilatations  and  other 
measures,  much  of  the  debris  of  the  system  which  has  long 
been  stagnant,  is  aroused  and  carried  away  and  when  the 
necessary  operation  is  finally  performed,  there  is  much  less 
general  disturbance  of  the  system  for  the  patient  to  contend 
with.  His  powers  are  less  taxed  and  his  benefit  is  correspond- 
ingly more  speedy  and  satisfactory. 

It  is  a  very  good  plan  in  delicate  cases  when  it  comes  to 
the  operation  after  the  preparatory  work  has  all  been  done,  to 
administer  a  hypodermic  injection  of  a  small  dose  of  morphine 
at  the  time  of  beginning  the  anaesthetic.  This  reduces  the 
amount  of  anaesthetic  required,  lessens  the  shock  to  the  sys- 
tem, and  insures  a  satisfactory  reaction.  [H.  M.  C.  is  better 
than  morphine. — Ed.] 


176  ORIFIG1AL   SURGERY. 

Orificial  surgery  has  passed  through  a  terrible  test  of  its 
merits  up  to  the  present  time.  It  has  appealed  to  the  profes- 
sion and  asked  for  simply  the  incurable  cases;  it  has  solicited 
simply  the  debris  of  professional  work;  the  cases  which  have 
been  incurable  by  all  other  measures  combined;  the  offscour- 
ings of  professional  practice.  It  has  sought  for  the  paralytics, 
asthmatics,  dyspeptics,  insane  and  all  other  incurable  affec- 
tions; cases  so  sleepy  in  the  march  of  life  that  it  seems  as 
though  little  short  of  Gabriel's  trumpet  could  speak  loud 
enough  to  them  to  once  more  arouse  their  systems  to  healthy 
action. 

Orificial  surgery  has  proved  its  remarkable  power  to 
arouse  active  reaction  in  this  class  of  cases,  and  thousands  up- 
on thousands  of  suffering  humanity  have  been  restored  to 
health  and  happiness  by  the  employment  of  its  measures  which 
before  were  doomed  to  lingering  disease  and  premature  de- 
parture from  this  life. 

The  measures  employed  for  this  class  of  cases  have  been 
severe,  but  the  cases  were  severe.  When  nature  sleeps,  a  meas- 
ure whose  aim  is  to  arouse  her  will  will  have  to  be  propor- 
tioned to  the  profundity  of  the  slumber;  but  all  this  vast 
amount  of  experience  with  orificial  methods  accumulated  by 
the  small  army  of  workers  in  this  new  specialty  has  proven 
one  thing  beyond  question,  namely,  the  power  of  the  work. 

When  opium,  or  morphine,  or  cocaine,  or  chloroform,  or 
ether,  or  any  other  narcotic  has  been  imbibed  to  the  point 
where  death  is  imminent,  so  imminent  indeed  that  artificial 
respiration,  electricity,  nitrite  of  amyl,  inversion  of  the  pa- 
tient, transfusion  and  all  other  means  known  to  the  profession 
for  resuscitating  a  narcotized  patient  have  been  of  no  avail, 
orificial  methods  have  been  repeatedly  employed  with  success. 
It  is  now  becoming  very  widely  known  that  the  rectal  bivalve 
is  the  greatest  resuscitator  on  earth.  It  has  sobered  the 
drunken,  awakened  the  narcotized,  revived  the  asphyxiated ; 
and  dilatation  of  the  anus  has  also  repeatedly  introduced  the 
stillborn  infant  to  its  first  gasp  of  breath  when  its  life  seemed 
a  forlorn  hope. 


OEEFIC1AL    SUE&EBY.  177 

Now  that  it  has  proved  itself  such  a  power  and  has  cured 
such  a  large  percentage  of  cases  which  by  other  means  have 
been  incurable,  in  its  next  stage  of  development  it  will  be  con- 
sidered as  a  means  of  prevention  as  well  as  cure  of  disease; 
for  as  stupid  as  humanity  is  in  some  respects,  it  really  does  a 
little  quiet,  sober  thinking  once  in  a  while;  and  there  is  a 
phrase  apropos  in  the  present  connection  which  has  long  been 
crystallized  as  an  axiom  of  human  experience,  namely,  "it  is 
easier  to  prevent  than  it  is  to  cure." 

In  surgery  everybody  knows  that  if  you  can  cure  bed- 
sores, you  can  prevent  them  and  people  must  be  aroused  to 
the  same  philosophy  in  chronic  diseases — if  they  can  be  cured 
they  can  be  prevented.  It  takes  terribly  harsh  and  severe 
measures  when  they  are  desperately  ill  to  cure  them.  It  will 
take  much  milder  and  gentler  forms  of  treatment  to  prevent 
them  getting  sick. 

This  principle  is  well  illustrated  in  the  history  of  den- 
tistry. It  is  within  the  memory  of  all  of  us  when  the  main 
business  of  the  dentist  was  to  pull  teeth  aid  furnish  false 
sets.  It  was  bloody  work,  painful  work,  destructive  work,  but 
it  stopped  the  toothache  and  enabled  people  to  masticate  their 
food  a  good  deal  better  than  they  could  with  a  mass  of  irri- 
table decayed  teeth  in  their  mouths.  But  what  a  change.  The 
best  dentists  today  do  not  pull  teeth  at  all  or,  at  least,  in  very 
exceptional  cases.  They  regard  it  as  a  poor  compliment  to 
their  skill  if  they  cannot  take  a  badly  dilapidated  mouth  and 
restore  it  to  a  good  condition  without  tooth  pulling.  And  the 
people  have  become  so  enlightened  upon  this  subject  that 
they  know  now  that  tooth  pulling  is  unnecessary  and  that  if 
they  will  only  go  to  a  dentist  in  time,  when  the  cavities  are 
very  small,  by  keeping  their  teeth  in  constant  repair,  they  can 
retain  their  natural  teeth  during  their  lives. 

So,  the  dentists  have  already  run  this  gamut  of  their  ex- 
perience. They  have  stopped  destroying  and  have  educated 
people  to  the  point  where  their  main  work  is  in  the  line  of 
prevention;  and  what  a  grand  progress  to  have  made  in  such 
a  short  time  as  they  have  been  at  work  in  this  direction, 


178  ORIF1CIAL   SUKGERY. 

Does  this  not  furnish  us  an  example  of  what  will  be  re- 
quired of  Orificial  Surgery?  If  it  can  take  this  army  of 
broken-down,  dilapidated,  distorted  and  badly  maimed  mass 
of  humanity,  all  included  in  the  general  list  known  as  chronic 
diseases,  and  cure  such  a  large  proportion  of  them,  it  can  cer- 
tainly, by  earlier  attention  to  the  lower  orifices  of  the  body, 
prevent  them. 

One  of  the  difficulties  of  the  situation  lies  in  the  fact  that 
the  orificial  irritation  which  does  the  most  mischief  is  not  pain- 
ful and  consequently  presents  no  symptoms  of  which  the  pa- 
tient is  conscious,  and  he  does  not  know  he  is  out  of  order  and 
wasting  his  nerve  power  unless  he  is  told  so  by  a  competent 
examiner. 

Sexual  waste  is  not  painful,  spasmodic  contraction  of  the 
internal  sphincter  caused  by  the  presence  of  pockets  or  pa- 
pillae or  any  other  form  of  irritation  in  the  last  inch  of  the 
rectum  is  not  painful  and  these  sources  of  nerve  waste  can  go 
on  indefinitely  until  the  reactive  power  of  the  patient  is  well- 
nigh  spent,  without  the  patient  being  in  the  least  degree  con- 
scious of  any  form  of  irritation  whatever. 

The  dentists  have  had  the  advantage  over  us  in  this  re- 
spect; when  the  tooth  is  decayed  to  a  sufficient  extent  the  pa- 
tient will  suffer  enough  pain  to  drive  -him  to  the  operating 
chair  for  relief.  But  the  nerve  waste  which  orificial  surgeons 
are  seeking  to  correct  is  so  painless,  because  it  is  that  of  the 
sympathetic  nerve  instead  of  the  cerebro-spinal,  that  it  takes 
a  high  degree  of  education  to  comprehend  that  the  entire  list 
of  human  ills,  in  all  their  varieties,  may  be  induced  by  morbid 
conditions  so  remote  from  the  part  apparently  affected. 

In  other  words  an  appreciation  of  the  meaning  of  peris- 
taltic actions  and  of  reflexes  and  other  topics  essential  to  the 
knowledge  of  orificial  principles  involves  a  degree  of  educa- 
tion which  will  necessarily  require  much  time  to  accomplish, 
but  it  must  be  done. 

Sick  and  suffering  humanity  are  appealing  to  us  for  relief 
so  strongly  that  we  cannot  escape  the  cry,  but  must  struggle 
on  in  the  great  work  we  have  undertaken. 


ORIFIG1AL    SURGERY.  179 

I  visited  the  other  day  one  of  the  State  Insane  Asylums  of 
Wisconsin.  There  were  over  six  hundred  inmates  of  this  in- 
stitution. No  effort  is  made,  whatever,  to  cure  these  cases ; 
they  are  simply  clothed,  housed,  fed  and  sufficiently  guarded 
to  prevent  injury  to  themselves  and  their  fellow  prisoners. 
There  is  another  and  still  larger  institution  of  the  same  kind 
in  the  State.  There  are  still  more  such  institutions  with  still 
more  inmates  in  the  State  of  Illinois ;  and  these  two  States  are 
no  exceptions  to  the  other  States. 

The  insane  of  this  country  are  among  the  hundreds  of 
thousands  with  not  a  voice  raised  or  a  hand  lifted  for  their  re- 
lief. If  the  people  only  knew,  if  the  doctors  only  knew  that 
this  entire  army  of  howling  maniacs  were  simply  suffering  the 
tortures  of  physical  distress  which  it  is  possible  to  remove,  and 
that  fully  three-fourths  of  them  could  be  restored  to  their 
right  minds,  their  health  and  their  friends  by  the  application 
of  orificial  methods  in  a  few  weeks'  time,  our  task  would  be  a 
lighter  one. 

My  friend',  tlrs  fact  is  not  known,  it  is  not  believed;  but 
you  and  I  know  it  and  our  task  is  no  light  one,  to  enlighten 
the  public  and  the  profession  in  this  direction.  The  help  which 
is  at  our  command  must  be  extended  to  the  insane  and  our 
duty  will  not  be  well  done  until  the  magical  action  of  ori- 
ficial work  is  made  possible  for  this  most  distressed  and  piti- 
ful class  of  chronic  sufferers. 

Chronic  sufferers  generally  can  shift  for  themselves.  They 
can  read,  they  can  investigate,  they  will  hear  of  the  accom- 
plishments of  Orificial  Surgery  and  apply  for  relief  in  due 
time  without  any  effort  upon  our  part.  All  we  have  to  do  is 
to  cure  cases  and  the  good  news  will  spread ;  but  it  will  not 
reach  the  insane  in  this  way.  These  poor  victims  of  reflex 
irritation  have  lost  their  judgment  and  have  been  deprived  of 
the  very  means  by  which  otherwise  they  could  search  for  res- 
pite from  their  pitiable  condition. 

It  is  your  duty  and  mine  to  see  to  it  that  the  attention  of 
the  authorities  who  have  charge  of  this  class  of  cases  is  at- 
tracted to  the  curative  power  of  orificial  methods  and  that  suf- 
ficient pressure  is  brought  to  bear  upon  them  to  induce  them 


180  ORIFIG1AL   SURGERY. 

to  give  their  patients  the  benefit  of  the  work.  Such  cases  can- 
not be  taken  to  sanitariums,  they  cannot  be  treated  well  at 
their  homes.  The  place  to  inaugurate  the  treatment  is  right 
in  the  insane  asylums  themselves. 

It  is  not  enough  for  these  cases  that  the  grounds  are  am- 
ple, the  surroundings  pleasant  and  that  they  have  food,  light 
and  air  and  general  hygienic  measures. 

They  had  all  these  at  home  but  they  have  gone  daft  from 
the  physical  conditions  of  their  bodies;  and  is  it  not  a  crying 
Bhame  that  not  a  hand  is  lifted  anywhere  to  pull  these  thorns 
from  the  flesh,  to  relieve  these  agonizing  sufferers  from  their 
living  death? 

For  my  part,  although  I  am  not  pugilistic,  my  blood  boils 
and  I  feel  like  joining  a  crusade  in  this  direction;  and  here 
again  comes  in  the  thought  that  prevention  is  better  than 
cure.  These  cases  are  desperate  ones  and  will  require  the  se- 
verest of  measures. 

What  a  grand  achievement  it  wjll  be  for  us  when  people 
begin  to  recogn:ze  the  fact  that  it  is  no  more  n?  *:ural  to  lie,  or 
commit  adultery,  or  steal,  or  to  violate  mental  laws,  than  it  is 
to  limp  or  wheeze  or  cough  or  show  physical  weakness  in  any 
particular;  when  these  aberrations  from  correct  rules  of  liv- 
ing will  be  regarded  as  disease  and  we  will  be  permitted  to 
employ  our  knowledge  of  orificial  principles  earlier  in  the  his- 
tory of  our  cases,  when  we  can  be  appealed  to  to  keep  bodies 
in  order,  to  prevent  disease  rather  than  to  cure  it ;  having  now 
proved  the  power  of  the  work  and  what  can  be  done  in  the 
most  desperate  of  all  classes  of  cases,  even  after  hope  has  be- 
come forlorn  and  visions  of  future  health  and  happiness  have 
grown  dim. 

Let  us  agitate  this  subject  until  we  arouse  our  kind  to  an 
appreciation  of  the  fact  that  chronic  diseases  can  be  prevent- 
ed ;  that  it  is  more  essential  to  keep  the  lower  openings  of  the 
body  in  repair  than  it  is  the  upper  ones;  that  it  is  not  neces- 
sary to  wait  until  one  is  at  death's  door  to  receive  the  ad- 
vantage from  the  knowledge  which  orificial  surgeons  possess; 
but,  that  it  is  much  better  to  submit  to  an  occasional  examina- 
tion and  be  kept  in  order,  thus  insuring  healthy  peristaltic 


ORIFICIAL    SURGERY.  181 

actions,  an  even  distribution  of  the  blood  current,  universally 
successful  and  satisfactory  nutrition  and  its  attendant  bless- 
ings. 

In  other  words,  let  us  work  on  in  our  field  of  labor  until 
the  world  at  large  begins  to  realize  that  it  is  easier  to  prevent 
than  it  is  to  cure,  and  that  what  can  be  cured  can  certainly  be 
prevented. 


CHAPTER  XXV. 


A  CONSIDERATION  OF  ORIPICIAL  METHODS  AND 
OPERATIONS. 


E.   H.   PRATT,   M.   D. 


If  we  have  succeeded  in  our  purpose  thus  far,  it  will  be 
evident  to  those  of  our  readers  who  have  kept  the  thread  of 
our  logic,  that  all  chronic  cases,  upon  examination,  will  be 
found  to  present  some  form  of  orificial  irritation  sufficient  to 
explain  the  lowered  vitality  which  has  permitted  them  to  re- 
main in  an  abnormal  state. 

In  all  forms  of  chronic  diseases,  therefore,  from  functional 
derangements  to  the  deeper  forms  of  pathology,  the  lower 
openings,  which  involve  the  waste  of  sympathetic  nervous 
force,  and  which  are,  therefore,  responsible  to  a  certain  ex- 
tent, for  a  lack  of  reactive  power  on  the  part  of  the  patient. 

Chronic  diseases  always  have  two  causes,  a  predisposing 
and  an  exciting  cause.  If  we  are  correct  in  our  position,  ori- 
ficial irritation  is  the  predisposing  cause  of  chronic  diseases 
generally.  If  this  be  true,  the  first  step  in  the  treatment  of 
chronic  cases  should  be  to  remove  the  first  cause ;  that  is,  to 
correct  the  orificial  irritation  and  stop  at  once  the  prodigal 
waste  of  nerve  force  involved.  How  to  accomplish  this  with 
safety  and  with  certain  benefit  to  the  patient  is  a  great  prob- 
lem, which  we  shall  now  consider  as  thoroughly  and  carefully 
as  is  consistent  with  the  space  and  ability  at  our  command. 


182  ORrFlCTAL   SURGERY. 

Orificial  surgery  is  an  edged  tool — it  can  cure,  it  can  also 
kill.  After  all  other  means  known  to  the  medical  profession 
for  the  relief  of  human  suffering  have  failed  to  re-establish 
health,  orificial  surgery  can,  in  a  majority  of  cases,  produce 
such  startling  and  satisfactory  results  as  to  be  a  perpetual 
surprise  and  consolation  even  to  those  who  are  familiar  with 
its  marvelous  power.  It  often  seems  well-nigh  impossible  to 
become  familiar  with  the  application  of  the  work  to  the  vari- 
ous forms  of  chronic  diseases,  to  escape  entirely  the  feeling 
of  astonishment  at  the  rapidity  and  surprising  transformations 
which  are  common  in  the  experience  of  every  orificial  surgeon. 
When  a  human  being  has  suffered  from  asthma  for  twenty 
years  to  a  distressing  degree,  until  life  has  become  a  burden, 
to  see  the  entire  difficulty  disappear  like  magic  from  a  piece  of 
surgical  work,  which  should  not  occupy  more  than  fifteen  or 
twenty  minutes  in  its  performance,  will  always  astonish  the 
operator,  no  matter  how  many  times  such  wonderful  trans- 
formations may  come  under  his  observation.  When  dyspepsia, 
which  has  been  so  persistent  as  to  require  the  use  of  a  stomach 
tube  daily  for  a  number  of  years,  disappears  in  a  single  day 
as  the  result  of  a  little  orificial  work,  the  change  will  always 
be  an  awe-inspiring  one  to  the  operator.  When  an  eczema  of 
many  years'  standing  will  entirely  melt  away  without  the  aid 
of  medicine  in  the  short  space  of  a  week's  time,  and  some- 
times sooner,  under  the  magic  touch  of  orificial  surgery,  it 
never  ceases  to  be  a  wonder  how  such  results  can  be  accom- 
plished. 

One  orificial  surgeon  who  has  been  familiar  with  the  mar- 
velous action  of  the  work  for  many  years,  writes  only  recently, 
"The  effect  of  the  work  upon  cases  of  phthisis  in  the  first  and 
second  stages  is  truly  startling  in  many  cases."  Another  emi- 
nent practitioner  of  extensive  orificial  experience  is  still  sur- 
prised at  his  marvelous  successes  in  his  treatment  of  cases  of 
insanity. 

Insomnia,  constipation,  chronic  diarrhoea,  epilepsy,  par- 
alysis, dropsy,  exophthalmic  goitre,  neuralgia,  chronic  head- 
aches, etc.,  are  repeatedly  cured  with  such  marvelous  com- 


ORIFICTAL    SURGERY.  183 

pleteness  and  rapidity  as  to  be  a  perpetual  surprise  even  to 
the  most  experienced  operators. 

But  there  is  another  side  of  the  picture  which  should 
never  be  lost  sight  of.  All  cases  are  not  brilliant  ones ;  nor  do 
all  result  satisfactorily  in  the  end.  Orificial  surgery  can  not 
only  rekindle  the  blaze  of  life  when  it  is  burning  low,  but  it 
can  also  extinguish  it.  It  should  always  be  remembered  that 
it  is  not  merely  local  work,  but  that  it  Always  exerts  a  pro- 
found effect  upon  the  entire  capillary  system  of  the  body,  af- 
fecting profoundly  all  its  functions  and  conditions. 

How  will  it  be  possible  ever  to  tell  the  story  of  its  curative 
action  graphically,  and  at  the  same  time  represent  the  mis- 
chief which  it  is  capable  of  doing,  so  that  every  doctor  who 
employs  it  as  a  means  of  cure  will  always  make  such  wise  se- 
lection of  the  cases  in  which  he  deems  it  applicable,  that  he 
will  invariably  employ  it  for  good,  and  never  for  harm?  Such 
excellence  of  judgment  has  never  yet  been  achieved  with  any 
other  remedial  measure.  Drugs,  massage,  electricity,  baths, 
mental  therapeutics,  and  all  other  healing  measures  at  the  com- 
mand of  the  medical  profession,  are  likewise  agencies  for  either 
good  or  harm,  according  to  the  skill  with  which  they  are  ad- 
minstered.  And  even  with  these  measures  humanity  is  fre- 
quently hurt,  as  well  as  helped;  it  is  often  permanently  in- 
jured, even  to  the  point  of  death,  as  well  as  satisfactorily  re- 
lieved of  its  distresses.  So  long  as  human  judgment  is  thus 
prone  to  err  in  everything  else,  it  is  scarcely  to  be  expected 
that  orificial  surgery,  which  is  more  potent  for  good,  and  con- 
sequently for  harm,  than  any  other  measure,  will  be  employed 
with  any  greater  degree  of  skill  and  judgment. 

Our  duty  to  the  profession  will  have  been  done  when  we 
have  presented  not  only  the  good  of  which  the  work  is  capable, 
but  also  the  harm;  and  we  shall  endeavor,  before  our  task  is 
ended,  to  so  truthfully  represent  not  only  the  possibilities  of 
the  work,  but  also  the  work  as  it  actually  is,  recording  its  fail- 
ures as  well  as  its  successes,  that  to  all  fair-minded  members 
of  the  medical  profession  it  will  be  made  to  appear  in  its  true 
light,  neither  embellished  by  the  gaudy  coloring  of  excessive 


184  ORIFICIAL   SUROERY. 

enthusiasm,  nor  obscured  by  the  over-caution  of  a  too  excess- 
ive conservatism. 

Let  us  take  it  for  granted,  then,  that  all  sufferers  from 
chronic  disease  are  also  possessed  of  orificial  irritation,  and 
that  their  permanent  recovery  demands  its  removal.  We  are 
then  prepared  to  consider  the  application  of  orificial  princi- 
ples and  methods  to  chronic  diseases,  and  to  estimate  them  at 
their  true  value.  Orificial  work  is  not  necessarily  operative 
work,  and  in  the  employment  of  the  philosophy  the  orificial 
surgeon  will  readily  divide  his  cases  into  two  classes:  first, 
those  demanding  operative  interference;  and  second,  those 
who  can  be  cured,  or  sufficiently  benefited  by  simpler  orificial 
measures. 

Hippocrates  wrote  that  all  measures  which  produce  a 
sudden  change  in  the  circulation  of  the  body  are  dangerous 
ones  and  should  be  handled  with  extreme  caution.  We  can 
endorse  the  wisdom  of  this  statement,  and  therefore  begin  the 
consideration  of  the  application  of  orificial  surgery  to  the 
treatment  of  chronic  diseases  with  the  caution  that  great  care 
and  judgment  must  be  exercised  in  the  employment  of  orificial 
methods. 

Let  us  first  consider  briefly  the  non-operative  measures  at 
the  command  of  orificialists  and  the  cases  to  which  they  are  ap- 
plicable. In  general  terms  these  consist  of  dilatation  of  the 
sphincter-guarded  openings  of  the  body  and  the  application  of 
heat  and  cold,  and  dryness  and  moisture,  and  massage  and 
electricity  employed  locally. 

DILATATION. 

In  all  cases  where  dilatation  is  to  be  practiced,  it  is  bet- 
ter to  make  use  of  graded  sizes  of  cylindrical  tools  in  prefer- 
ences to  valvular  ones,  when  practicable,  because  it  involves  an 
evener  dilatation  and  less  bruising  of  the  parts.  Dilatation 
is  servicable  in  the  rectum,  in  the  male  and  female  urethra,  in 
the  vulva  and  vagina,  and  in  the  uterus.  Considering  dilata- 
tion of  these  parts  in  the  order  in  which  they  have  been  named, 
we  will  first  speak  of  the  dilatation  of  the  rectum.  For  this 
purpose  rectal  plugs  are  frequently  serviceable. 


ORIFIC1AL    SURGERY.  185 

DILATATION  OF  THE  RECTUM. 

It  is  well  to  begin  with  the  smaller  sizes  and  pass  on  to 
the  use  of  the  larger  ones  as  the  parts  become  accustomed  to 
their  use.  Rectal  plugs  can  be  employed  daily,  or  weekly,  or 
bi-weekly,  and  can  be  immediately  withdrawn  after  insertion, 
or  permitted  to  remain  for  half  an  hour  or  two  hours,  at  the 
discretion  of  the  surgeon,  the  size  employed  depending  upon 
the  comfort  of  the  patient,  and  the  length  of  time  they  are  al- 
lowed to  remain  introduced  depending  upon  the  extent  of  re- 
action which  it  is  desirable  to  secure. 

Dilatation  of  the  anus  affects  more  profnundly  the  respi- 
ration, and  consequently  the  capillary  circulation,  than  that 
of  any  other  of  the  lower  openings  of  the  body.  In  health, 
nature  secures  a  daily  flushing  of  the  capillaries  by  the  pas- 
sage of  large,  solid  masses  of  faecal  matter.  In  cases  of 
chronic  constipation  and  chronic  diarrhoea,  the  system  fails 
to  receive  its  daily  benediction  of  renewed  vitality,  and  suf- 
fers from  a  lack  of  it.  The  rectal  plugs  may  be  made  to  act 
as  a  substitute  for  natural  dilatation  in  such  cases,  and  un- 
aided by  other  measures,  will  often  restore  the  habit  of  the 
bowel  to  a  normal  state,  after  which  their  use  can  be  aban- 
doned. The  dilators  can  be  used  daily  in  such  cases  until  they 
have  established  a  satisfactory  reaction  and  the  habit  becomes 
normal,  or  until  the  irritation  which  they  sometimes  induce 
causes  a  feeling  of  pressure  at  the  base  of  the  brain,  or  local 
soreness,  when  their  use  should  be  suspended  for  a  time  until 
the  irritation  has  passed  away,  after  which  they  can  be  again 
employed  and  their  action  continued  until  health  is  restored, 
or  they  fail  to  be  of  further  service  to  the  patient. 

Rectal  dilatators  may  be  employed  not  only  by  physicians, 
but  may  be  entrusted  to  the  keeping  of  intelligent  patients  to 
be  used  at  their  own  discretion.  The  use  of  a  rectal  dilator 
when  one  is  tired  is  more  invigorating  than  stimulants.  They 
are  also  of  service  in  resuscitating  a  patient  from  an  epileptic 
seizure,  or  a  fainting  fit,  from  opium  or  other  poisoning,  and 
from  drowning.  They  are  remarkably  efficacious  in  aiding  a 
new-born  infant  to  its  first  gasp  of  breath,  and  in  establishing 
reaction  after  prolonged  illness,  as  typhoid  fever,  diphtheria, 


186  ORIFICIAL    SURGERY. 

pneumonia,  gastritis,  etc.  They  are  good  for  a  tired  brain  and 
a  tired  body  and  are  perhaps  superior  to  any  other  general  or 
remedial  agent  as  an  invigorating  tonic.  In  severe  cases,  as 
those  of  convulsions,  it  is  well  to  use  the  larger  sizes  at  once, 
allowing  them  to  remain  in  position  at  the  discretion  of  the  at- 
tending physician. 

The  attention  of  the  laity,  as  well  as  the  profession,  should 
be  attracted  to  the  action  of  the  rectal  dilators,  until  the  fact 
becomes  well  known  and  established,  that  anal  dilatation 
flushes  the  capillaries  of  the  body  universally,  thus  immediate- 
ly equalizing  the  circulation  and  thereby  relieving  local  con- 
gestions wherever  they  may  be  located,  be  they  in  the  head, 
kidneys,  stomach,  liver  or  elsewhere. 

If  the  most  important  truth  which  the  orificial  philosophy 
has  presented  to  the  world  were  to  be  selected,  it  would  be 
that  anal  dilatation  flushes  the  capillaries,  and  has  a  tendency 
to  readjust  the  inharmonious  action  of  a  diseased  body,  what- 
ever form  its  deviation  from  normal  standards  may  take. 

The  benefit  of  heat  or  cold,  or  the  alternation  of  the  two, 
may  be  added  to  that  of  dilatation  by  employing  what  is  known 
as  the  Eldridge  dilators,  these  being  the  same  form  as  those  al- 
ready mentioned,  differing  from  them  in  the  possession  of  an 
adjustable  top,  upon  the  removal  of  which  the  hollowed  di- 
lators can  be  filled  with  hot  or  cold  water  at  pleasure.  Some- 
times the  prolonged  application  of  combined  heat  or  cold  and 
dilatation  at  the  anus  is  invaluable  as  a  means  of  resuscitation. 

We  can  recall  one  case  in  which  a  knowledge  of  this  fact 
was  the  means  of  saving  a  life.  A  pregnant  woman  near  her 
confinement  was  suffering  with  acute  Bright 's  disease,  which 
terminated  finally  in  convulsions,  demanding  her  immediate 
delivery.  The  child  was  safely  delivered  and  lived,  but  soon 
afterwards  the  mother  suffered  a  return  of  the  convulsions  in 
such  a  severe  and  persistent  form  that  it  was  deemed  neces- 
sary to  keep  her  under  the  continued  action  of  chloroform  for 
many  hours  in  succession.  For  three  hours  she  stood  the  se- 
vere ordeal  without  the  convulsions  and  without  apparent 
harm.  After  that  time  she  became  gradually  cyanotic,  her 
chest  filled  with  mucus,  and  the  further  administration  of 


ORIFICIAL    SURGERY.  187 

chloroform  became  extremely  dangerous.  At  the  same  time 
it  was  deemed  equally  dangerous  to  permit  her  to  awaken  from 
the  anaesthetic,  as  sufficient  time  had  not  yet  elapsed  to  ensure 
her  against  the  return  of  the  convulsions.  In  this  extremity,  a 
rectal  dilator  was  inserted,  through  which  a  return  stream  of 
hot  water  could  be  passed  thus  administering  to  her  the  double 
effect  of  dilatation  and  dry  heat  at  the  anus.  Imagine  the 
feeling  of  delight  which  her  physicians  experienced  when  they 
saw  the  cyanosis  disappear  and  the  circulation  of  the  lungs 
become  so  thoroughly  established  as  to  be  entirely  cleared  of 
their  obstructing  mucus  in  the  short  space  of  five  minutes' 
time.  And  this,  too,  while  she  was  still  inhaling  the  fumes  of 
the  chloroform.  After  employing  the  heat  and  dilatation  for 
about  fifteen  minutes  it  was  discontinued,  and  she  was  again 
safely  narcotized  for  several  hours,  when  once  more  it  was 
necessary  to  resort  to  the  same  measures  for  re-establishing 
her  vitality.  She  was  kept  anaesthetized  by  chloroform  by  the 
aid  of  the  dilatation  and  heat  occasionally  applied  at  the  anus, 
for  eighteen  hours,  after  which,  as  all  convulsive  symptoms 
had  passed  away,  she  was  permitted  to  awaken  from  the  an- 
aesthetic. The  convulsions  never  returned  and  she  made  a 
rapid  recovery,  which  in  her  case  we  are  satisfied  would  not 
have  been  possible  had  it  not  been  for  the  employment  of  the 
heat  and  dilatation. 

When  the  case  is  extreme,  as  in  threatened  death  from 
chloroform — not  like  the  case  just  described,  but  in  case  of  a 
sudden  cessation  of  respiration  and  circulation,  or  in  cases  of 
drowning,  or  convulsions,  or  syncope — the  bivalve  speculum 
is  perhaps  more  serviceable  than  the  rectal  plugs,  as  dilatation 
in  such  cases  is  needed  beyond  the  capacity  of  the  plugs ;  al- 
though great  care  must  always  be  exercised  not  to  overdo  the 
dilatation,  because  it  is  possible  in  any  case  to  put  out  a  flick- 
ering flame  of  life  in  a  careless  effort  to  merely  fan  it  back 
into  a  steady  flame. 

As  we  have  no  interest  whatever  in  the  sale  of  tools,  never 
having  patented  an  instrument  of  our  invention,  nor  possessed 
any  interest  whatsoever  in  their  sale,  we  feel  at  liberty  to 
speak  freely  of  their  general  usefulness. 


188  OBIFICTAL   SURGEEY. 

The  rectal  plugs  are  not  desirable  as  means  of  dilatation 
for  operative  purposes,  at  least,  unless  still  larger  sizes  are 
employed  than  those  already  in  the  market.  The  bivalve 
speculum  employed  under  an  anaesthetic  is  so  satisfactory  a 
means  of  securing  a  proper  degree  of  dilatation  in  all  cases 
where  an  operation  upon  the  anus  is  contemplated,  that  it  will 
in  time  come  to  be  universally  relied  upon  for  this  purpose. 
The  manner  and  proper  time  for  securing  dilatation  for  oper- 
ative procedure  will  be  discussed  in  connection  with  the  va- 
rious operations  upon  the  rectum  to  be  later  described  in  this 
series  of  articles. 

One  word  more  about  dilatation  of  the  anus  before  we  dis- 
miss the  subject.  From  the  remarks  already  made  it  will  be 
inferred  that  it  is  of  great  service  as  a  general  measure  in  the 
various  forms  of  chronic  disease.  It  is  also  serviceable  for  some 
forms  of  local  trouble.  Unaided  by  any  other  measure, 
the  use  of  the  rectal  plugs  will  relieve  both  bleeding  and  blind 
piles.  They  will  overcome,  in  a  great  majority  of  cases,  a  con- 
stricted anus,  and  will  strengthen  and  restore  to  a  normal 
state  a  relaxed  enervated  one.  They  will  not  take  the  place  of 
the  more  radical  measure  of  orificial  surgery  by  any  means,  at 
the  same  time  they  occupy  an  important  place  in  the  list  of 
orificial  measures.  It  must  always  be  remembered  that  the 
work  is  orificial  and  not  rectal  and  that  in  an  effort  to  correct 
rectal  conditions  it  will  almost  invariably  become  necessary  to 
consider  the  condition  of  the  other  orifices  in  the  pelvic  region. 

DILATATION  OF  THE  FORESKIN. 

This  has  been  practiced  by  a  good  many  physicians  in 
cases  of  contracted  prepuce,  in  hopes  to  avoid  the  use  of  the 
knife,  and  the  practice  is  favored  by  a  large  number  of  intelli- 
gent practitioners  of  medicine.  Personally  we  have  been  so 
satisfied  with  the  more  radical  forms  of  procedure  where  the 
foreskin  is  in  an  abnormal  state,  that  we  have  never  given  the 
process  of  dilatation  a  sufficient  trial  to  enable  us  to  deal  with 
the  subject  fairly. 

Where  the  foreskin  is  either  too  long  or  too  tight,  we  have 
been  so  accustomed  to  the  operation  of  circumcision,  and  to  the 


OEIFIC1AL    SURGERY.  189 

dorsal  slit,  and  been  so  satisfied  with  results  obtained  that  we 
have  had  no  occasion  to  abandon  the  practice  for  the  purpose 
of  experimenting  with  dilatation.  For  this  reason  we  should 
like  to  hear  from  those  who  have  practiced  dilatation  as  to  the 
degree  of  satisfaction  which  they  obtain  from  it. 

DILATATION  OF  THE  MALE  URETHRA. 

It  is  best  accomplished  by  the  use  of  graded  steel  sounds. 
Personally  we  prefer  the  Van  Buren  sound,  and  are  accus- 
tomed to  the  English  numbering.  The  double  sounds,  which 
we  have  had  constructed,  were  designed  to  economize  in  num- 
ber and  weight  of  instruments,  and  are  in  every  way  satis- 
factory. 

The  sounds,  like  the  rectal  plugs,  have  a  general  and  local 
use.  As  sexuality  is  sustained  by  the  sympathetic  nervous  force, 
the  tonicity  of  the  sexual  organs  may  be  taken  as  an  index  of 
the  quality  and  character  of  peristaltic  actions  throughout  the 
body.  States  of  sexual  excitability  indicate  an  irritable  condi- 
tion of  the  involuntary  muscles  which  surround  all  iftbular 
structures,  and  patients  suffering  from  this  affliction  arc  prone 
to  active  congestion  of  whatever  part  may  be  weakest  or  most 
severely  taxed.  On  the  other  hand,  sexual  weakness  or  atony 
is  an  index  of  weakened  peristaltic  actions,  and  an  invariable 
precursor  of  whatever  passive  congestions  the  general  system 
may  be  subject  to. 

The  employment  of  sounds,  either  hot  or  cold,  or  both,  is 
a  necessary  remedial  measure  for  these  opposite  conditions. 
While  it  will  allay  irritability  of  the  sexual  organs  and  its  ac- 
companying general  sympathetic  hyper-aesthesia,  it  will  also 
restore  wasted  sexual  powers  to  their  normal  condition,  and 
thus  act  as  a  universal  sympathetic  tonic.  They  may  be  in- 
serted and  immediately  withdrawn  or  permitted  to  remain 
from  half  an  hour  to  two  hours;  they  may  be  employed  either 
hot  or  cold,  or  employed  both  hot  and  cold  at  the  discretion 
of  the  surgeon,  as  in  the  case  of  the  rectal  plugs.  Unlike  the 
rectal  plugs,  however,  they  should  never  be  used  by  the  pa- 
tient, but  always  employed  solely  by  the  physician.  Any  one 
of  ordinary  intelligence  can  introduce  a  rectal  plug  of  proper 


190  ORIFIG1AL   SURGERY. 

size  without  detriment,  but  the  proper  use  of  male  soimds  is  a 
matter  of  such  delicacy  that  they  are  often  harmful  even  in 
the  hands  of  physicians  themselves.  We  cannot,  therefore, 
too  strongly  urge  even  physicians  to  be  cautious  in  their  use. 

When  they  are  to  be  employed  for  their  general  effect 
upon  the  entire  system,  the  size  of  the  sound,  the  length  of 
time  it  should  be  left  in  position,  and  the  question  as  to 
whether  it  should  be  employed  hot  or  cold,  or  both,  depends 
entirely  upon  the  reactive  power  of  the  patient.  In  cases  of 
nervous  irritability,  where  reaction  is  speedy,  the  mere  intro- 
duction and  removal  of  a  warm  sound  will  give  the  sympa- 
thetic nervous  system  a  sufficient  impetus  to  restore  it  to  a 
normal  state.  In  states  of  sympathetic  anaesthesia,  however, 
where  all  the  bodily  processes  are  sluggish  and  indolent,  it 
may  be  necessary  to  leave  a  warm  sound  in  position  from  half 
an  hour  to  two  hours,  and  follow  this  with  the  introduction 
of  a  cold  sound,  which  should  be  left  not  longer  than  one  or 
two  minutes,  repeating  the  process  once  or  twice  a  week  until 
symptoms  of  general  and  local  reaction  manifest  themselves. 

No  routine  ti  jatment  for  the  use  of  sounds  can  be  laid  down 
which  will  be  applicable  to  all  cases,  but  always  cases  must 
be  individualized  and  the  sounds  employed  according  to  the 
wants  of  each  case. 

There  is  a  urethral  dilator  invented  by  Dr.  Nils  Bergman, 
of  the  Lincoln  Park  Sanitarium,  by  means  of  which  vibratory 
dilatation  can  be  secured  in  the  prostatic  urethra,  which  serves 
a  good  purpose,  especially  in  atonic  cases. 

In  merely  local  affections  of  the  urethra,  where  the  nerve 
waste  has  not  sufficiently  drained  the  general  reservoir  of  sym- 
pathetic nervous  force  to  fluctuate  the  general  condition  of  the 
system,  the  use  of  graded  steel  sounds  may  also  be  demanded. 

In  the  treatment  of  abnormal  sexual  excitability,  as  well 
as  for  the  cure  of  stricture  and  gleet,  they  are  indispensable. 
They  are  equally  indispensable  in  the  treatment  of  impotency. 
As  in  all  other  tubular  structures  dilatation  will  overcome  un- 
due tension,  and  will  also  restore  integrity.  Sounds  are  there- 
fore equally  serviceable  in  the  spasmodic  conditions  of  the 
urethra  and  in  flabby  states  of  the  same  canal.  This  dis- 


ORIFIC'IAL    SURGERY.  191 

tinction  should  be  made,  however,  in  the  treatment  of  these 
opposite  conditions:  In  contracted  and  irritable  states,  the 
sounds  should  be  employed  warm,  and  should  not  be  left  long 
in  position ;  in  the  opposite  condition,  they  should  be  employed 
either  cold  or  alternately  hot  and  cold,  and  should  be  per- 
mitted to  remain  in  position  for  a  varying  length  of  time,  in 
order  to  secure  a  satisfactory  degree  of  reaction. 

By  referring  to  another  article  of  this  series  it  will  be 
seen  that  the  most  important  part  of  the  male  urethra  is  the 
prostatic  inch.  From  this  it  will  be  appreciated  that,  in  em- 
ploying urethral  sounds  for  any  purpose  whatsoever,  they 
should  always  be  made  to  enter  the  bladder,  as  their  efficiency 
in  influencing  sexual  conditions  depends  upon  their  action 
upon  the  prostatic  part  of  the  urethra. 

To  better  illustrate  the  influence  of  sexual  conditions  over 
the  general  circulation,  it  may  be  well  to  describe  two  cases, 
one  showing  the  influence  which  the  foreskin  exerts  upon  the 
general  health  of  the  body,  and  the  other  illustrating  what 
can  be  done  with  urethral  dilatation,  even  in  extreme  cases. 

Some  ten  years  ago  we  were  called  upon  to  consider  the 
case  of  a  child  nine  months  old.  The  child  had  never  slept 
well  since  its  birth,  and  vomited  most  of  the  food  that  was 
taken  into  its  stomach,  and  was  so  emaciated  that  it  weighed 
one  pound  less  than  it  did  when  it  was  three  months  old. 

After  prescribing  for  the  child  to  the  best  of  our  ability 
for  a  month  or  two,  and  succeeding  in  doing  nothing  more 
than  merely  enabling  it  to  retain  what  little  food  it  could 
swallow,  we  advised  a  change  of  climate.  After  a  three 
months'  absence  I  was  again  consulted  in  regard  to  the  case, 
and  to  my  distress  found  that  the  child  had  not  been  improved 
by  its  trip.  On  the  contrary,  in  addition  to  its  previous  dif- 
ficulties, marasmus  and  wakefulness,  it  had  become  dropsical 
in  the  lower  half  of  its  body.  Feeling  my  inability  to  treat 
the  case  successfully,  I  called  Professor  J.  W.  Streetor  in 
counsel.  The  child  appeared  to  be  making  an  effort  to  cut  the 
upper  front  teeth,  and  its  gums  were  lanced.  A  change  of 
treatment  was  suggested  by  Dr.  Streeter,  which  was  consci- 
entiously followed  out,  but  to  no  purpose. 


192  ORIFIC1AL   SURGERY. 

Being  thoroughly  nonplussed  as  to  the  cause  of  the  mal- 
nutrition which  the  case  presented,  I  had  the  child  stripped 
and  made  an  examination  of  the  lower  part  of  the  body — its 
spine,  its  liver,  etc.  At  that  time  I  did  not  appreciate  the  in- 
fluence of  sexual  conditions  over  nutrition.  In  fact,  this  was 
one  of  the  cases  that  set  me  to  thinking  profoundly  of  the  in- 
fluence of  the  sympathetic  nerve  and  its  use  in  the  economy  of 
the  system.  As  I  was  taking  a  complete  invoice  of  every  thing 
I  could  observe  about  the  body,  however,  I  examined  the  penis, 
and  found  that  the  opening  was  quite  a  small  one — in  fact,  so 
small  that  it  was  with  difficulty  that  I  could  bring  the  point  of 
the  penis  to  view.  I  attracted  the  attention  of  the  mother  to 
the  condition,  and  told  her  of  the  evil  effects  of  an  adherent 
foreskin  upon  the  future  morals  of  the  boy,  and  told  her  that 
it  was  a  wholesome  measure  to  secure  freedom  of  this  part,  al- 
though I  could  not  promise  that  it  would  have  any  influence 
upon  his  present  condition.  She  told  me  to  do  whatever  I 
thought  best.  The  child  was  so  weak  that  I  feared  to  circum- 
cise it,  nor  did  I  appreciate  at  that  time  that  it  was  important 
to  do  so.  So  I  took  a  grooved  director  and  thoroughly  loos- 
ened the  foreskin  from  the  glans  penis,  liberating  a  small 
amount  of  smegma.  With  a  scalpel  I  then  slit  the  foreskin 
along  the  dorsum,  and  instructed  the  mother  to  pull  the  edges 
of  the  wound  apart  several  times  a  day,  so  that  they  would  not 
adhere  together  and  reproduce  the  strictured  condition.  The 
next  day  when  I  called  the  mother  informed  me  that  the  child 
had  slept  all  night  for  the  first  time  in  its  life,  and  had  awak- 
ened in  the  morning  hungry.  Without  medicine  or  any  other 
treatment  the  child  continued  to  improve,  until  at  the  end  of 
a  week  all  symptoms  of  dropsy  had  entirely  disappeared  and 
the  patient  was  apparently  convalescent.  This  was  a  great 
professional  surprise,  and  I  at  once  began  to  ponder  upon  the 
reason  for  such  a  remarkable  effect  from  so  simple  a  measure. 

My  reflections  were  considerably  disturbed  in  about  two 
weeks,  however,  when  the  mother  again  summoned  me  to  ex- 
amine her  boy.  There  was  a  surprise  in  store  for  me  at  this 
visit  of  an  entirely  different  character.  To  my  deep  chagrin, 
the  dropsy  had  returned,  but  instead  of  taking  the  form  of 


ORIFICIAL    SURGERY.  193 

swollen  limbs  and  abdomen,  which  it  assumed  on  its  first  ap- 
pearance, it  came  back  in  the  form  of  hydrocephalus.  Water 
had  accumulated  in  the  cranial  cavity  to  such  an  extent  that 
the  head  was  of  an  enormous  size,  the  frontals  were  bulging, 
and  the  bones  of  the  head  had  so  separated  that  a  finger  could 
be  placed  along  any  of  the  cranial  sutures  without  impinging 
upon  bone  tissue.  The  forehead  protruded  so  prominently  be- 
yond the  face  that  the  eyes  seemed  to  have  moved  back  into 
the.  head.  The  weight  of  the  head  was  such  that  the  child  was 
wholly  unable  to  support  it  and  it  had  to  be  carried  on  a  pil- 
low. The  mother,  of  course,  was  desperate  and  had  given  up 
all  hopes  of  the  child's  recovery.  I  asked  her  if  she  had  kept 
the  foreskin  retracted  and  the  lips  of  the  wound  separated. 
She  said  she  had.  I  asked  to  examine  the  boy,  and  she  re- 
fused to  permit  me.  After  an  hour's  struggle  with  her,  how- 
ever, reminding  her  of  the  marvelous  effects  of  the  previous 
work,  which  showed  conclusively  that  the  foreskin  was  the 
cause  of  the  child's  ill  health,  I  finally  secured  an  examina- 
tion and  to  my  gratification  I  found  that  the  mother  had  failed 
to  do  her  part  satisfactorily.  The  edges  of  the  wound  had 
healed  together,  the  foreskin  had  been  permitted  to  become 
again  glutinated  to  the  glans  penis,  and  the  parts  were  really 
in  a  worse  condition  than  before  they  had  been  touched. 

I  now  insisted  upon  and  succeeded  in  performing  circum- 
cision upon  the  child.  From  this  time  on  improvement  began, 
and  in  the  course  of  two  weeks  the  hydrocephalus  had  entirely 
disappeared,  at  which  time  the  case  was  safely  and  finally  dis- 
missed. The  child  has  grown  into  a  healthy  lad,  and  has  never 
been  ill  since  the  experience  which  I  have  just  related. 

After  such  an  experience  I  was  thoroughly  convinced  that 
the  condition  of  the  parts  and  the  end  of  the  penis  exercised 
considerable  influence  over  general  nutrition. 

Another  case.  I  was  summoned  by  Prof.  L.  C. 
Grosvenor,  of  Chicago,  in  counsel  in  a  case  of  dropsy.  The  pa- 
tient was  a  man  about  fifty  years  of  age  and  presented  a  truly 
pitiable  appearance.  He  had  been  sitting  in  a  chair,  eating 
and  sleeping  in  a  chair,  wholly  unable  to  assume  the  recum- 
bent position  for  two  months  and  a  half.  He  had  anasarca  to 


194  OBIFIC1AL   SUEGERY. 

an  extreme  degree.  In  the  lower  limbs  it  was  so  extensive 
that  the  skin  seemed  to  be  stretched  to  its  possibilities;  it  was 
glazd  from  its  extreme  tension.  Several  punctures  had  been 
made  in  the  skin  about  the  ankles  to  relieve  the  pressure,  and 
around  these  openings  there  was  a  slight  tendency  to  eczema. 
The  face  was  badly  puffed  and  mottled  in  appearance,  as  were 
also  the  arms,  hands — and  in  fact  the  entire  body.  There  was 
also  considerable  ascites.  The  pericardium  was  partly  filled 
with  water,  and  there  was  hydrothorax  of  the  left  pleura  to 
such  an  extent  that  the  cavity  was  three-fourths  filled  with 
water,  the  right  side  being  clear. 

Prof.  Grosvenor  is  an  exceptionally  good  prescriber,  and 
I  felt  that  in  that  respect  I  was  in  the  presence  of  my  su- 
perior, so  I  remarked  to  him,  "Dr.  Grosvenor,  if  I  could  start 
that  man's  capillary  circulation  do  you  suppose  it  would  be  of 
any  benefit  to  him?"  He  replied,  "Most  certainly."  "Very 
well,"  said  I,  "you  have  been  trying  for  two  months  and  a 
half  to  do  it  with  drugs  and  have  failed.  It  is  useless  for  me 
to  attempt  to  improve  upon  your  prescriptions.  On  account  of 
the  man's  inability  to  lie  down  it  is  impossible  to  employ 
rectal  dilatation,  but  the  introduction  of  urethral  sounds  will 
certainly  have  some  effect  upon  his  capillary  circulation,  al- 
though the  case  appears  like  a  hopeless  one."  The  doctor  ex- 
pressed his  willingness  to  follow  my  suggestions,  as  well  as  his 
lack  of  confidence  in  the  measure.  Prof.  Grosvenor  is  an  hon- 
est man,  however,  and  freely  admitted  that  his  prejudice 
against  the  measure  was  from  lack  of  knowledge  of  its  useful- 
ness, and  from  no  other  cause.  He  therefore  consented  to  fol- 
low out  any  line  of  treatment  that  I  would  suggest.  I  re- 
quested him  to  procure  a  No.  14  Van  Buren  sound,  pass  it 
into  the  urethra  and  let  it  lie  there  for  about  five  or  ten  min- 
utes, and  then  remove  it,  and  continue  with  the  medicine  he 
was  already  giving  the  patient.  He  found  some  difficulty  in 
gaining  the  consent  of  the  members  of  the  family  to  the  meas- 
ure, but  finally  succeeded  in  accomplishing  the  introduction 
of  the  sound  as  agreed  upon.  Five  days  later  we  again  met  in 
counsel  on  the  same  case,  and  much  to  my  gratification  I  ob- 
served that  the  skin  about  the  ankles  and  feet  was  less  shiny, 


ORIFIC1AL   SURGERY.  195 

less  eczematous,  and  beginning  to  display  faint  wrinkles  up- 
on its  surface,  showing  a  decrease  in  tension.  The  ascites  was 
about  the  same,  but  the  hydrothorax  was  markedly  less,  the 
left  thoracic  cavity  being  not  more  than  one-half  full  of  fluid, 
whereas  at  the  first  time  I  visited  him  it  had  been  three-fourths 
full.  The  expression  of  the  face  was  less  anxious  and  its  mot- 
tled appearance  had  greatly  disappeared,  the  breathing  was 
much  better,  and  in  many  other  respects  the  patient  was  re- 
markably improved.  I  advised  another  introduction  of  the 
sound  and  the  other  treatment  continued  as  before. 

I  never  saw  the  man  again,  but  was  informed  by  Dr.  Gros- 
venor  that  at  the  end  of  a  week  from  the  time  of  my  first  visit 
the  man  was  able  to  assume  a  horizontal  position  in  sleeping; 
three  days  later  lie  was  so  far  relieved  as  to  be  able  to  ex- 
ercise in  the  open  air;  one  month  later  he  was  so  completely 
restored  to  health  that  he  resumed  his  business  and  has  been 
a  well  man  ever  since. 

It  should  be  mentioned  that  the  sound  was  used  at  an  in- 
terval of  every  five  days  for  several  times  after  my  first  con- 
sultation with  the  doctor.  This  man  had  never  had  gonorrhoea ; 
had  always  been  a  temperate,  virtuous  man  in  every  respect, 
and  the  only  symptom  which  would  suggest  a  sexual  tonic  in 
his  case  was  a  diminution  in  sexual  activity,  which  had  been 
increasing  for  four  or  five  years  previous  to  his  attack  of 
dropsy. 

I  believe  that  at  the  second  examination  I  made  an  ef- 
fort to  examine  the  rectum,  but  obtained  no  satisfaction  from 
it  as  the  parts  were  so  dropsical  and  the  position  so  uncom- 
fortable for  the  patient  that  it  was  deemed  best  to  defer  at- 
tention to  this  part.  The  subsequent  recovery  of  the  case  ren- 
dered it  apparently  unnecessary,  so  that  what  rectal  trouble 
he  has  still  remains  statu  quo,  unless  the  mere  dilatation  of 
the  rectum  employed  in  making  the  examination  has  cured  it. 

This  case  was  an  extreme  one  and  exceptionally  happy  in 
its  results.  But  it  is  no  less  a  satisfactory  illustration  of  the 
influence  which  urethral  conditions  exercise  over  the  general 
system  and  what  can  be  done  in  the  way  of  general  repairs  by 
urethral  dilatation. 


196  ORIFICIAL   SURGERY. 

Results  are  not  always  so  satisfactory,  although  they  are 
more  frequently  so  than  the  general  profession  dreams  of. 

Before  closing  the  present  article  we  must  call  attention 
once  more  to  the  fact  that  sexual  conditions  are  frequently 
influenced  by  the  rectum,  and  that  it  is  needless  to  expect  to 
overcome  abnormal  sexual  conditions  without  due  respect  be- 
ing paid  to  the  last  inch  of  the  rectum.  It  is  often  necessary, 
therefore,  to  alternate  the  use  of  sounds  and  the  use  of  rectal 
plugs  in  order  to  secure  satisfactory  results.  It  may  be  re- 
marked, however,  in  general,  that  a  longer  time  may  be  al- 
lowed for  reaction  from  urethral  dilatations  than  from  dilata- 
tion of  the  rectum.  In  other  words,  the  rectal  plugs  may  be 
used  to  advantage  at  shorter  intervals,  as  a  rule,  than  would 
be  proper  in  the  employment  of  sounds. 

CHAPTER  XXVI. 


ORIFICIAL  SUGGESTIONS. 


E.   H.   PRATT,   M.   D. 


Orificial  surgery  has  presented  to  the  medical  world  a 
large  number  of  original  operations,  and  also  a  great  many  im- 
provements in  already  established  methods  of  surgical  pro- 
cedure applied  to  the  organs  of  the  pelvis.  These  operations 
have,  most  of  them,  been  already  so  frequently  and  clearly  de- 
scribed from  time  to  time  in  the  pages  of  the  Journal  of  Ori- 
ficial Surgery,  as  well  as  in  other  periodicals,  that  it  would 
scarcely  be  worth  while  to  invite  your  consideration  to  any  of 
them,  but  rather  to  the  great  fact  that  many  cures  can  be  ef- 
fected, and  a  wonderful  amount  of  good  accomplished,  in  both 
acute  and  chronic  diseases,  generally  and  locally,  by  orificial 
methods  which  do  not  involve  an  operation.  Many  cases  de- 
manding operative  interference  as  a  sine  qua  non  of  recovery 
are  ill-conditioned  for  it,  and  the  nature  of  the  work  to  which 
I  desire  to  call  your  attention  is  beneficial  also  in  such  cases 
as  preparatory  work.  The  measures  are  also  useful  as  after- 
treatment  following  operative  procedures. 


ORIFIC1AL    SUEGERY.  197 

The  chief  measures  at  the  hands  of  the  orificialist  to  which 
I  desire  to  call  your  attention  are: 

First.     Water. 

Second.    Massage. 

Third.    Sounds. 

Fourth.     Tampons  and  rectal  plugs. 

Fifth.     Local  feeding. 

First,  water.  This  time-honored  remedy  for  the  ills  of 
humanity  is  not  yet  sufficiently  appreciated  by  doctors  in  gen- 
eral and  orificialists  in  particular,  and  therefore  deserves  first 
consideration.  It  has  long  been  used  as  a  douche  in  pelvic 
cellulitis  in  women,  but  its  soothing  influence,  when  poured 
over  the  pudenda,  has  not  been  sufficiently  appreciated  or 
taken  advantage  of.  These  pelvic  organs  are  supplied  by  pen- 
cils of  nerve  trunks  starting  from  common  centers,  so  that 
influences,  either  beneficial  or  harmful,  applied  at  any  of  the 
terminal  nerve-fibers  of  this  pencil  can  be  felt  and  influence 
the  irritability,  and  hence  the  blood-supply  and  the  functions 
and  pathology  of  any  of  the  parts  supplied  by  the  remaining 
fibers  of  the  various  pencils  of  nerves.  For  instance,  an  ir- 
ritation at  the  neck  of  the  bladder  in  the  male,  as  from  a 
stone  in  the  bladder,  can  cause  pain  and  irritability  at  the 
point  of  the  penis.  This  physiological  fact  can  be  utilized  by 
recognizing  the  applicability  of  the  converse  of  this  proposi- 
tion— that  applications  made  to  the  point  of  the  penis  can  in- 
fluence the  neck  of  the  bladder. 

As  a  result  of  this  suggestion  it  will  be  found  serviceable 
to  hold  the  point  of  the  penis  in  water,  as  hot  as  can  be  borne, 
for  a  few  minutes  after  the  passage  of  sounds,  in  both  acute 
and  chronic  inflammation  of  the  urethra,  the  bladder,  and  also 
the  kidneys.  The  influence  of  the  heat  to  the  point  of  the 
penis  extends  along  the  entire  urinary  tracts,  because  the 
nerve-supply  of  these  organs  comes  from  a  common  center. 

The  same  fact  can  be  utilized  in  the  female  by  douching 
the  pudenda  with  hot  water  for  inflammatory  conditions  of 
the  bladder,  vagina,  uterus,  ovaries  and  tubes,  and  also  the 
kidneys. 


198  ORIFIGTAL   SURGERY. 

Hot  water  applied  to  the  anus  will  check  the  hemorrhage 
of  bleeding  piles,  and  also  the  hemorrhage  following  slit-work 
upon  the  rectum.  It  will  also  speedily  remove  ecchymosis  and 
soreness  of  the  anus.  In  cases  of  chronic  constipation  o¥*irri- 
tation  or  congestion  of  the  sexual  organs,  a  teacupful  of  hot 
water  thrown  into  the  rectum  daily,  preferred  after  the  bow- 
els are  moved,  and  to  be  retained,  will  be  found  of  great 
utility.  Cold  water,  if  introduced  into  the  rectum,  or  into  the 
vagina  or  male  urethra,  is  liable  to  induce  rheumatic  and  neu- 
ralgic afflictions,  and  is  not  to  be  commended ;  but  upon  the 
pudenda  and  outside  of  the  anus  it  is  often  very  beneficial  in 
restoring  tonicity  to  parts  which  have  lost  it,  and  in  arousing 
the  general  reactive  powers.  After  its  use  the  parts  should 
be  thoroughly  dried  with  a  towel  and  rubbed  and  chafed  until 
a  satisfactory  degree  of  reaction  has  supervened. 

In  resuscitating  patients  who  have  collapsed  from  an  an- 
esthetic or  a  narcotic  of  any  kind  where  dilatation  of  the 
rectum,  urethra,  or  uterus  has  proved  insufficient,  water,  as 
hot  as  can  be  used  without  blistering,  poured  over  the  pu- 
denda will  many  times  afford  satisfactory  stimulation,  and  aid 
materially  in  inducing  general  reaction. 

It  is  a  wholesome  measure  to  bathe  the  base  of  the  body 
daily  in  either  hot  or  cold  water  as  a  sanitary  as  well  as  an  in- 
vigorating measure,  hot  water  being  preferred  in  those  of  a 
neuralgic  or  rheumatic  tendency,  and  in  an  individual  of  poor 
reactive  power,  cold  water  being  otherwise  preferred. 

Second,  massage.  It  is  serviceable  in  the  rectum  for  slug- 
gishness and  atony  of  the  organ,  being  especially  serviceable 
in  cases  of  chronic  constipation.  In  irritability  of  the  anus, 
and  also  in  hemorrhoidal  conditions,  it  is  an  agent  of  great 
utility.  Care  should  be  taken,  before  employing  it,  to  have 
the  parts  thoroughly  douched  and  lubricated  with  vaseline,  so 
that  the  proceeding  may  be  neither  poisonous  to  the  manipu- 
lator nor  uncomfortable  to  the  patient.  Through  the  rectum 
massage  can  be  employed  for  chronic  prostatic  troubles.  In 
acute  prostatitis  it  is  a  dangerous  agent,  as  it  is  liable  to  be 
followed  by  such  energetic  reaction  as  to  cause  abscess,  or, 
what  is  still  more  liable,  orchitis,  especially  if  the  upper  part 


ORIFIG1AL    SURGEKY.  199 

of  the  prostate  is  bruised  so  as  to  injure  the  prostatic  terminus 
of  the  ejaculatory  ducts.  For  chronic  affections  of  the  pros- 
tate, however,  where  a  wholesome  reaction  is  desirable,  the 
measure  is  exceedingly  effective,  although  care  is  always  re- 
quired in  the  manipulation  of  the  prostate  to  prevent  harmful 
results.  Massage  of  the  sexual  organs  in  either  sex  is  contra- 
indicated  in  acute  conditions,  but  in  chronic  affections,  pre- 
senting either  hypertrophy  or  atrophy,  it  is  one  of  the  most 
reliable  of  measures  for  restoring  the  sexual  organs  to  their 
equilibrium. 

To  employ  the  measure  for  good  instead  of  harm  requires 
some  considerable  knowledge  of  the  art,  as  well  as  a  purity  of 
purpose  on  the  part  of  the  manipulator,  and  for  this  reason 
alone  is  not  to  be  carelessly  prescribed  or  employed. 

Third,  male  and  female  sounds.  These  are  serviceable, 
not  merely  to  overcome  strictured  conditions  and  secure  free 
vent  for  the  discharge  of  secretions  and  excretions,  but  they 
are  wonderfully  effective  in  restoring  sexual  tone  to  organs 
which  for  many  causes  have  been  unduly  depleted.  In  irrita- 
bility of  the  organs  hot  sounds  should  be  used,  while  in  atony 
they  had  better  be  employed  first  hot  and  then  cold.  The 
length  of  time  for  which  they  can  be  used  to  advantage  will 
vary  from  a  period  of  two  or  three  minutes  to  as  many  hours, 
the  question  being  always  one  of  surgical  judgment,  which  is 
to  be  based  solely  upon  personal  experience  and  knowledge  of 
the  case  under  consideration.  The  frequency  of  their  repe- 
tition is  always  a  matter  of  surgical  judgment,  as  sometimes 
for  a  brief  period  their  daily  use  may  be  beneficial,  while  at 
other  times  an  interval  of  one,  two,  or  even  four  weeks  may 
not  be  too  long.  Their  use  is  serviceable,  of  course,  not  simply 
for  their  local  effect,  but  for  their  influence  over  the  entire 
sympathetic  nerve,  and  consequently  the  general  bodily  nu- 
trition. 

Fourth,  tampons  and  rectal  plugs.  Vaginal  tampons  have 
for  many  years  been  freely  employed  in  gynecological  work. 
They  were  formerly  constructed  of  cotton,  but  of  late  years 
wool  has  been  preferred.  Their  early  use  was  mainly  as  a 
means  of  uterine  support.  For  this  purpose  they  have  been, 


200  ORIFIG1AL  SURGERY. 

to  a  great  measure,  dispensed  with,  the  employment  of  pes- 
saries and  operative  procedures  supplanting  them.  As  a  ve- 
hicle for  the  topical  application  of  drugs  to  the  vaginal  vault, 
however,  they  are  still  in  favor,  and  probably  always  will  be. 
The  employment  of  tampons  in  the  sigmoid  has  never,  until 
the  invention  of  the  sigmoid  speculum,  been  of  practical 
utility.  Now,  however,  they  are  frequently  employed  as  a 
vehicle  for  the  application  of  medicine  to  the  sigmoid,  and  for 
this  purpose  are  frequently  of  inestimable  value.  Ulceration 
and  irritability  and  catarrh  of  the  sigmoid  are  mischievous 
conditions  which  have  been  almost  entirely  overlooked  until 
late  years.  But  now  they  are  known  to  be  so  common  a  source 
of  reflex  mischief  that  sigmoidal  treatments  have  grown  in 
favor  with  the  profession,  and  one  of  the  most  effective  means 
of  medicating  the  sigmoid  is  by  means  of  medicated  tampons. 
A  tampon  can  be  placed  in  the  sigmoid  and  permitted  to  re- 
main there  until  expelled  with  the  descending  feces.  Irriga- 
tion of  the  sigmoid  by  means  of  Cole's  sigmoid  irrigator,  or 
some  similar  instrument,  is  a  rival  of  the  sigmoid  tampon,  be- 
cause its  employment  is  sometimes  quite  as  effective  and  its 
use  involves  less  discomfort  to  the  patient  and  less  skill  on  the 
part  of  the  doctor.  Cases  are  frequent,  however,  in  which  the 
irrigator  is  not  adequate  to  the  purpose,  and  sigmoid  tam- 
pons are  the  only  satisfactory  means  of  meeting  the  demands 
of  the  case. 

Rectal  plugs  are  of  ancient  origin,  for  they  were  in  use 
as  long  ago  as  when  Pompeii  was  buried  by  the  ashes  and  lava 
of  Vesuvius.  From  time  to  time,  however,  their  usefulness 
has  been  forgotten  by  the  profession.  The  traditional  soap 
suppository  of  midwives,  for  constipated  infants,  is  probably 
a  relic  of  a  previous  knowledge  which  was  in  the  possession  of 
the  profession,  but  long  since  forgotten.  The  present  medical 
era,  however,  is  marked  by  a  concerted  movement  on  the  part 
of  medical  men,  and  laymen  as  well,  in  the  direction  of  anal 
dilatation.  It  has  been  found  serviceable,  not  only  in  anal 
stenosis,  but  also  in  general  debility,  as  its  action  is  more 
stimulating  than  whisky,  and  a  greater  tonic  than  any  pre- 
scription of  drugs  known  to  the  medical  fraternity.  Anal  di- 


ORIFIC1AL    SUEGERY.  201 

latation  deepens  inspirations,  flushes  capillaries  and  inaugu- 
rates general  nutrition.  The  most  common  forms  of  accom- 
plishing this  is  by  means  of  rectal  plugs  of  graduated  sizes. 
The  size  employed,  the  length  of  time  for  which  it  is  to  be  re- 
tained, and  the  frequency  of  its  use,  all  have  to  do  with  the 
irritability  or  the  sluggishness  of  not  only  the  anus  but  of  the 
entire  individual.  The  object  of  their  employment  is  always 
in  all  cases  to  secure  either  local  or  general  reaction,  accord- 
ing to  the  purpose  for  which  it  is  employed. 

There  are  many  forms  of  rectal  plugs  now  upon  the  mar- 
ket, but  as  they  all  have  the  same  object  in  view,  and  are 
equally  efficacious,  there  is  scarcely  ground  for  choice  in  their 
selection.  The  Weirick,  Young,  Linn,  and  other  makes  too 
numerous  to  mention  are  scarcely  to  be  considered  as  improve- 
ments upon  the  original  pattern  known  as  the  Pratt  rectal 
plug. 

In  selecting  rectal  plugs  it  would  be  well  to  secure  those 
which  are  hollow  and  provided  at  their  base  with  two  tubes, 
connecting  with  their  cavity.  Over  one  of  these  tubes  the  pipe 
of  a  fountain  syringe  can  be  employed,  while  over  the  other 
a  waste-pipe  is  fixed,  and  by  means  of  this  arrangement,  while 
dilatation  is  being  secured,  the  action  of  either  heat  or  cold 
can  also  be  brought  into  service. 

As  the  uses  of  anal  dilatation  are  already  pretty  widely 
known,  and  at  any  rate  they  are  too  extensive  to  be  enumer- 
ated in  the  present  paper,  further  comment  in  the  present  con- 
nection is  unnecessary. 

Fifth,  local  feeding.  It  has  long  been  known  to  the  pro- 
fession that  the  body,  in  general,  can  be  fed  with  some  con- 
siderable degree  of  satisfaction  by  the  application  of  local 
foods,  either  to  the  skin  or  to  its  accessible  mucous  mem- 
branes, that  of  the  rectum  being,  as  a  rule,  preferred.  But 
the  employment  of  nutritious  liquid  to  transform  mucous  and 
skin  surfaces  from  the  pallor  of  sickness  to  the  flush  of  health 
has  certainly  been  overlooked  and  forgotten  until  very  re- 
cently. The  fact  that  bovinine  was  serviceable  in  the  treat- 
ment of  chronic  varicose  ulcerations  led  to  its  employment  in 
gangrene  and  inflammatory  conditions,  and  then  to  restore 


202  ORIFICTAL   SURGERY. 

strength  and  tonicity  to  the  rectum,  vagina,  and  in  some  cases 
the  urethra,  until  now  the  knowledge  is  rapidly  spreading, 
and  local  conditions  of  pallor  are  being  made  under  its  in- 
fluence to  take  on  a  ruddier  hue.  Where  a  vaginal  hyste- 
rectomy or  an  operation  for  laceration  of  the  cervix  or  per- 
ineum, or  any  form  of  rectal  work  is  contemplated  for  the  re- 
lief of  the  case,  if  the  parts  involved  present  the  appearance 
of  malnutrition  to  such  an  extent  as  to  hazard  the  success  of 
the  work,  soaking  the  parts  once  or  twice  daily  with  bovinine 
for  a  few  weeks  will  institute  such  an  improved  condition  of 
the  parts  to  be  operated  upon  as  to  insure  success  where  other- 
wise defeat  would  have  been  inevitable.  Other  nutritious  prep- 
arations than  bovinine  in  all  probability  would  be  equally  ser- 
viceable, but  as  this  agent  has  given  satisfactory  service  for 
local  feeding,  it  has  left  insufficient  excuse  for  experimentation 
with  other  and  uncertain,  because  untried,  products. 

If  due  respect  is  paid  to  this  suggestion  of  local  feeding 
as  preparatory  treatment  for  operative  procedure  where  it  is 
demanded  in  delicate  cases,  surgical  work  will  score  an  in- 
creased percentage  of  success,  and  consequently  escape  much 
of  the  censure  which  otherwise  must  await  its  employment,  for 
even  the  most  skilfully  performed  surgical  operation  is 
doomed  to  failure  if  the  parts  operated  upon  are  too  feeble  to 
react,  too  starved  to  heal. 

CHAPTER  XXVII. 


THE  CONFIRMATION  OF  EXPERIENCE. 


C.    E.    SAWYER,   M.   D. 


It  is  an  easy  matter  to  make  assertions  or  to  originate 
theories,  but  it  is  quite  another  thing  to  promulgate  plans  of 
treatment  in  this  advanced  age  of  medical  science  that  will 
serve,  as  has  orificial  surgery,  to  revolutionize  the  general 
practice  of  medicine.  That  orificial  surgery  has  attained  this 
end  is  no  longer  questionable.  In  evidence  we  had  public 


OBIPIG1AL   SURGERY.  203 

institutions  conducted  and  operated  upon  its  principles  alone, 
colleges  with  special  chairs  for  its  teaching,  hospitals  with 
ample  wards  for  the  care  of  its  patients,  sanatoriums  with  sep- 
arate departments  for  its  eases,  and  surgeons  without  num- 
ber who  were  daily  practicing  its  laws  of  cure,  this  too,  when 
but  a  little  more  than  a  decade  had  elapsed  since  its  founder  re- 
vealed to  the  medical  profession  his  plan  of  benefiting  the  mul- 
titude of  heretofore  incurable  invalids.  Then  it  was  new,  un- 
tried, unpracticed;  an  infant  unable  to  stand  alone,  without 
experience  to  guide  or  practiced  hands  to  direct,  starting 
forth  on  its  mission  of  mercy,  accepting  for  its  subjects  the 
worst  of  the  leavings  and  culls  of  former  medical  and  surgical 
practice. 

It  has  from  this  beginning,  under  circumstances  most  ad- 
verse, reached  in  its  application  from  the  simplest  functional 
disorders  to  the  profoundest  organic  disease.  From  the  many 
trials  thus  incurred  it  has  of  necessity  met  some  failures,  some 
rebuffs,  but  it  has  also  scored  many  victories  impossible  to 
other  means,  and  today  stands  recognized  as  a  great  force  in 
the  combatment  of  disease.  As  its  fields  were  all  unexplored, 
and  as  the  armamentarium  to  be  employed  in  its  use  was  at 
first  restricted  to  a  few  crude  instruments,  and  as  the  direction 
of  its  course  was  in  the  hands  of  novices,  it  is  not  to  be  won- 
dered at  that  it  met  with  some  criticism,  the  justice  of  which 
is  appreciated  by  none  more  than  the  ardent  supporters  that 
have  continued  to  uphold  its  banner  through  the  trying  hours 
of  its  experimental  stage. 

Because  of  the  forced  empiricism  in  its  use,  no  conscien- 
tious doctor  ever  sought  its  benefits  without  feeling  a  certain 
degree  of  hesitancy  in  its  application,  and  until  sufficient  time 
had  elapsed  whereby  certain  fixed  rules  could  be  formulated 
it  was  always  a  question  to  conservative  surgeons  how  much 
might  really  be  expected,  how  much  could  honestly  be  prom- 
ised. To  those  who  have  been  faithful  in  the  application  of 
its  principles,  earnest  in  their  observation  of  its  uses,  and  hon- 
est in  their  conviction  of  its  results,  I  do  not  believe  there  is 
one  who  doubts  its  efficiency  or  but  that  has  been  benefited 
by  its  employment.  To  him  who  assumed  the  responsibility 


204  OBIFICTAL   SURGERY. 

of  its  operations  and  after-treatment  without  sufficient  knowl- 
edge and  skill,  there  no  doubt  has  come  disappointment. 

Unfortunately,  many  physicians  have  become  imbued  with 
the  belief  that  orificial  surgery  is  applicable  to  all  forms  of 
disease  in  all  classes  of  cases;  that  all  of  the  operations  are 
simple,  and  the  after-treatment  of  little  importance;  that  no 
special  surgical  ability  is  required,  no  professional  skill  need- 
ed; all  that  is  to  be  done  is  to  operate — a  position  false  in 
every  particular.  It  is  useless  to  attempt  a  work  of  such  mag- 
nitude as  that  of  orificial  surgery  without  a  proper  apprecia- 
tion of  its  requirements,  and  yet  many  doctors,  after  an  at- 
tendance of  but  a  single  course  of  these  most  interesting  clin- 
ics, return  to  their  homes  and  advertise  themselves  as  special- 
ists in  this  department,  the  presumption  of  which  is  only  out- 
ranked by  the  unreasonable  promises  they  make  their  patients. 

If  this  paper  has  no  other  object  it  is  to  be  hoped  it  may 
impress  upon  the  present  new  attendants  at  these  clinics  that 
time,  study,  observation  and  thorough  application  of  all  ori- 
ficial principles  are  to  be  duly  understood  before  being  war- 
ranted in  attempting  the  role  of  an  orificial  surgeon.  To  sup- 
port the  grand  and  growing  superstructure  which  affords  to 
suffering  humanity  its  greatest  boon,  whose  chief  object  is 
betterment,  whose  possibilities  are  unlimited,  and  whose  cli- 
max is  the  ultimatum  of  every  true  surgeon's  life — the  cure 
of  disease — it  is  well  that  we  each  look  with  careful  scrutiny 
into  the  details  that  make  such  results  possible. 

Experience  confirms  the  opinion  that  the  only  failures  of 
orificial  philosophy  come  either  from  a  lack  of  foresignht  in  the 
selection  of  cases,  unscientific  and  unskilled  application  of 
methods,  or  a  lack  of  proper  consideration  of  after-treatment 
principles.  To  prevent  the  unjust  criticism  that  results  from 
these  shortcomings  it  is  necessary  that  more  attention  be  given 
seemingly  little  things,  for  therein  lies  the  success  of  orificial 
surgery. 

Orificial  surgery  is  not  a  "cure-all."  It  simply  has  its  place 
among  the  most  valuable  forces  in  the  cure  of  disease,  and 
that  place  is  in  keeping  with  the  judgment  used  in  its  employ- 
ment. In  consequence  we  must  bow  in  deference  to  the  find- 


OBIFIC1AL    SURGERY.  205 

ings  of  experience  in  choosing  fitting  subjects  for  its  applica- 
tion, for  vast  importance  attaches  to  their  proper  selection, 
and  too  much  care  cannot  be  employed  in  this  regard.  Origi- 
nally there  was  no  guide  to  direct  in  this  matter,  but  now  we 
are  old  enough  to  have  established  some  fixed  rules  by  which 
to  be  governed,  and  as  it  is  experience  and  observation  that 
counts,  I  submit  mine  for  what  it  is  worth  in  offering  the  fol- 
lowing suggestions,  hoping  that  their  careful  consideration 
may  make  possible  some  useful  deductions. 

Candor  and  frankness  are  two  cardinal  principles  in  the 
success  of  any  surgeon's  work,  and  they  are  not  less  essential 
in  orificial  surgery  than  elsewhere.  It  is  both  unwise  and  un- 
professional to  make  promises  in  which  there  is  the  slightest 
doubt  as  to  fulfillment.  It  is  far  better  that  the  patient  as- 
sume the  risk  of  the  operation  without  undue  persuasion,  for 
it  is  much  more  satisfactory  to  all  to  give  more  than  is  prom- 
ised than  to  promise  more  than  can  be  given.  All  that  is  ever 
admissible  is  a  plain,  candid  statement  of  facts,  never  over- 
estimating the  possibilities,  never  under-rating  the  risks,  al- 
ways leaving  the  patients  to  decide  whether  or  not  they  wish 
to  accept  the  question  it  brings.  All  operative  work  should  be 
preceded  by  a  careful,  thorough  examination  of  the  individual 
before  submitting  them  to  the  necessities  of  an  anesthetic  or 
the  risk  of  an  operation.  Finding  serious  organic  complica- 
tions, it  is  always  advisable  to  proceed  carefully,  for  orificial 
surgery  is  a  double-edged  sword  liable  to  cut  both  ways,  and 
may  aggravate  as  well  as  cure. 

With  due  consideration  of  this  fact  many  unfavorable 
results  may  be  foregone,  and  many  calamitous  terminals  an- 
ticipated. Considerate  observation  demonstrates  that  the  best 
grounded  exceptions  taken  by  the  opposition  to  orificial  sur- 
gery are  based  upon  the  fact  that  sufficient  weight  is  not  given 
to  the  matter  of  selecting  cases.  There  is  no  more  reason  in 
a  haphazard  manner  of  choosing  orificial  cases  than  in  select- 
ing general  surgical  operative  cases,  and  the  failures  that  re- 
sult from  care  in  this  particular  can  not  be  less  injurious  to  one 
than  the  other.  The  realms  of  orificial  surgery  are  wide  enough 


206  OBIFIG1AL   SUROERY. 

without  assuming  undue  risk  or  inviting  criticism,  and  it  is 
unnecessary  to  engender  discredit  or  ridicule  by  doing  unrea- 
sonable things. 

That  we  may  not  justify  the  charge  of  absurdity  we  should 
in  all  cases  selected  use  the  greatest  discretion,  being  sure  that 
we  have  good  and  reasonable  grounds  upon  which  to  base  con- 
clusions. Next  in  importance  to  the  selection  of  cases  come 
modes  of  operation  and  methods  to  be  employed.  Here  again 
experience  teaches  that  the  best  rule  to  be  followed  is  that  of 
conservatism,  remembering  always  that  the  milder  forms  of 
treatment  are  oftentimes  capable  of  the  greatest  good,  and  un- 
less the  indications  are  clear  cut  or  the  immediate  necessities 
imperative,  it  is  always  advisable  to  consider  carefully  all  the 
bearings  of  the  case,  weighing  well  all  of  its  questions.  There 
is  no  more  reason  in  submitting  a  patient  to  an  American  oper- 
ation or  a  hysterectomy  unless  the  gravity  of  the  case  demands 
it  than  there  is  in  amputating  a  leg  for  a  corn  or  of  doing  a 
laparotomy  for  a  laceration. 

The  orificial  surgeon  who  serves  orificial  principles  best  is 
he  who  appreciates  the  power  of  the  force  he  is  wielding,  and 
who  understands  well  the  requirement  of  the  case  he  is  treat- 
ing that  he  may  use  with  certainty  the  means  to  be  employed. 
Because  an  individual  is  willing  to  submit  to  the  surgeon's 
desires  in  the  matter  of  operation  it  is  not  necessary  to  impose 
the  most  heroic  measures,  for  in  so  doing  he  may  overstep 
reasonable  bounds  and  injure  rather  than  benefit.  It  is  better 
by  far  that  discretion  be  the  watchword  and  the  simpler  meth- 
ods be  tried  first  than  that  discredit,  dissatisfaction  and  com- 
plaint be  brought  against  orificial  principles.  This  is  not  only 
true  of  orificial  operations  in  general,  but  is  just  as  true  of 
each  in  particular,  for  as  they,  as  a  whole,  have  their  indica- 
tions, so  have  they  separately,  and  it  becomes  every  orificial 
surgeon  who  would  succeed  best  to  learn  for  himself  the  im- 
portance of  individualization  both  in  regard  to  cases  chosen 
and  methods  employed.  Having  once  decided  upon  the  course 
of  pursuance,  care  in  the  preparation  of  the  case  and  thor- 
oughness in  the  execution  of  means  are  of  the  next  importance. 
No  case,  no  matter  how  slight  the  form  of  treatment  to  be  em- 


OBIFICTAL   SUEGEBY.  207 

ployed  or  the  malady  to  be  relieved  should  be  regarded  lightly, 
for  much  importance  attaches  to  having  the  ground  well  pre- 
pared before  the  seed  is  sown.  To  this  end  every  patient 
should  be  placed  in  the  most  favorable  condition  for  surgical 
procedure.  To  meet  this  end  it  is  required  of  all  that  careful 
aseptic  means  be  adopted  in  the  preparation  of  all  cases.  No 
orificial  surgeon  is  justified  in  compromising  orificial  princi- 
ples by  considering  lightly  any  case  under  his  observation,  for 
if  so  considered  by  the  surgeon  it  is  sure  to  be  by,  the  patient, 
consequently  the  moral  effect,  which  is  of  so  much  importance 
in  all  surgical  work  and  which  experience  will  not  allow  us  to 
disregard,  is  lost  and  thus  we  are  robbed  of  one  of  the  influ- 
ences that  serve  an  important  purpose  in  the  treatment.  If  a 
case  is  to  be  considered  at  all  it  is  worthy  all  the  knowledge 
and  skill  the  surgeon  possesses,  and  nothing  short  of  his  b?st 
efforts  should  be  given. 

This  rule  is  just  as  applicable  in  minor  operations  as  ma- 
jor ones,  and  care  in  this  regard  is  just  as  necessary  in  one  as 
the  other,  for,  as  the  supporting  power  of  the  foundation  is, 
so  is  the  magnitude  of  the  superstructure,  and  final  results 
may  always  be  anticipated  in  proportion  as  the  details  are  ex- 
ecuted. 

Thus  far  we  have  been  dealing  with  matters  of  import  af- 
fecting the  form  and  method  of  operation,  and  to  that  end  we 
have  been  judicious  in  selecting  cases.  We  have  chosen  with 
discriminating  care  the  meaiis  to  be  employed  and  our  pros- 
pects of  ultimate  success  are  correspondingly  favorable.  This, 
to  the  casual  observer,  would  seem  all  that  was  necessary,  but 
the  experienced  surgeon  knows  that  were  he  to  quit  even  here, 
many  cases  that  otherwise  might  be  recorded  as  cures,  react 
as  failures.  All  the  possibilities  have  not  been  achieved,  for 
in  the  after-treatment  comes  much  of  vital  interest  to  every 
orificial  case.  As  well  might  we  expect  the  stump  of  an  am- 
putated limb  to  require  no  other  attention  than  simply  the  op- 
eration for  removal,  as  to  hope  for  favorable  results  from  ori- 
ficial operations  without  proper  after-attention  and  treatment. 
This  not  only  includes  the  careful  treatment  of  the  wound  and 
the  favorable  adjunct  measures  such  as  electricity,  massage, 


208  OBIFIC1AL   SURGERY. 

etc.,  etc.,  but  it  has  to  do  as  well  with  habits  of  life  and  modes 
of  living. 

Many  cases  are  aggravated  and  complicated  by  errors  in 
diet,  unfavorable  environment,  and  lack  of  health-giving  regi- 
men, and  to  disregard  attention  to  these  demands  is  to  fail  in 
achieving  the  possibilities  in  many  cases.  Many  times  in  my  ex- 
perience have  I  had  cases  referred  to  me  still  serving  time  as 
chronic  invalids  after  favorable  operations  had  been  per- 
formed, simply  because  proper  regard  had  not  been  paid  the 
matter  of  after-consideration.  More  than  useless  is  the  effort 
to  cure  the  hand  of  a  burn  with  the  member  still  in  the  fire, 
and  yet  many  such  useless  efforts  are  put  upon  orificial  sur- 
gery by  many  of  its  would-be  friends  and  supporters.  If 
there  is  a  matter  which  should  be  in  ground  in  every  orificial 
surgeon's  mind  it  is  that  of  looking  with  careful  scrutiny  into 
habits,  surroundings,  and  modes  of  life  of  all  who  seek  the 
benefits  that  come  from  orificial  principles  well  applied. 

The  following  cases  will  serve  to  illustrate  the  responsi- 
bilities orificial  philosophy  has  been  made  to  bear  as  well  as 
the  importance  of  a  thorough  consideration  of  all  direct  and 
concomitant  circumstances  either  directly  or  indirectly  re- 
lated to  each  and  every  case: 

A  few  weeks  ago  a  woman  twenty -three  years  of  age,  of 
good  family  history,  was  brought  to  us  in  the  following  con- 
dition. She  was  weak,  anemic,  nervous,  sleepless,  pallid,  with 
poor  appetite,  constipated  bowels,  hectic  fever  and  a  slight 
cough.  Lying  as  she  did  on  the  stretcher  that  was  used  in  con- 
veying her  from  her  home,  she  looked,  as  she  was,  an  abject 
object  of  misery  and  discomfort.  For  three  long  years  she  had 
been  paying  tribute  to  the  throne  of  disease,  an  altogether  too 
willing  subject.  Such  had  been  her  invalid  habits  that  her 
physical  force  had  been  lowered  to  an  extreme  degree,  her 
blood  was  thin  and  colorless,  her  secretions  impoverished,  her 
vital  forces  depressed  and  her  mental  powers  obtunded. 

Upon  making  inquiry  as  to  what  lines  of  treatment  had 
been  adopted  in  her  case  I  learned  that  she  had  tried  all  of  the 
drug  provinces,  proprietary  and  prescribed  alike,  she  had  also 


OEIFIC1AL    SURGERY.  209 

been  a  subject  more  or  less  of  Faith  Cure  principles  and 
Christian  Science  treatments  and  thoroughly  applied  orificial 
principles  had  altogether  failed  to  relieve  her  of  her  bondage. 
This  at  first  seemed  strange  to  me  for  I  felt  sure  that  orificial 
principles  were  well  indicated  and  knowing  the  ability  of  the 
surgeon  who  had  operated  on  her,  I  did  not  question  the  ef- 
ficiency of  his  work.  A  careful  physical  examination  demon- 
strated that  such  was  the  case  for  all  of  the  orifices  were  in 
prime  condition,  consequently  I  was  led  to  look  for  shortcom- 
ings in  unfavorable  environments  or  imperfect  after-treat- 
ment and  herein  I  found  cause  sufficient  for  the  lack  of  favor- 
able results.  I  learned  that  she  had  been  continuously  under 
the  influence  of  a  constantly  sympathizing  mother  and  a  no 
less  sympathizing  sister  and,  worse  than  all,  an  undetermined 
doctor.  From  this  association  she  had  been  led  to  believe  that 
all  forms  of  exercise  were  harmful,  that  the  most  limited  diet- 
etic measures  were  to  be  employed  and  that  pains  and  aches 
and  distresses  were  to  be  looked  for.  Some  of  the  rules  by 
which  she  was  to  be  governed  whose  erroneousness  are  self-evi- 
dent, were  as  follows:  She  could  eat  nothing  but  liquid  food, 
she  must  take  nourishment  when  she  chose,  regardless  of  time 
day  or  night,  she  could  bear  no  sunlight,  even  imagining  the 
exposure  incident  to  the  proper  ventilation  of  her  room,  dan- 
gerous, she  must  have  a  light  burning  during  the  entire  night 
in  her  sleeping  apartment,  was  only  bathed  when  she  was 
forced  to  and  only  exercising  when  she  could  not  avoid  it. 

Such  were  the  unfavorable  conditions  in  which  she  was 
found  when  operated  upon,  and  these  same  conditions  re- 
mained uncorrected  after  the  operation,  consequently  the  lack 
of  benefit  from  the  orificial  treatment.  Although  orificial  phil- 
osophy was  well  indicated  and  should  have  cured,  yet  under 
these  circumstances  it  did  not,  nor  could  not,  effect  the  changes 
that  were  necessary  and  the  failure  was  charged  as  a  failure  to 
orificial  surgery,  the  propriety  and  justice  of  which  I  leave  for 
each  of  you  to  judge. 

Just  yesterday  my  attention  was  called  to  a  woman  38 
years  old  who  had  been  an  invalid  for  twelve  years;  during 
every  day  of  this  time  she  had  been  under  the  surveillance  of 


210  ORIFIG1AL   SURGERY. 

a  doctor  and  one  or  two  trained  nurses.  She  had  lain  for  the 
last  thirteen  months  on  her  right  side  and  back,  never  having 
turned  over  in  all  that  time.  She  is  extremely  nervous,  every 
little  noise,  every  unaccustomed  sound  is  very  distressing  to 
her;  even  a  ray  of  sunlight  adds  to  her  discomfort.  During 
all  this  time  the  entire  household  have  submitted  to  her  dicta- 
tion, and  she  demands  that  every  footstep  shall  be  muffled, 
every  tone  subdued,  every  action  qualified,  every  condition 
modified,  everything  changed  to  meet  her  personal  demands. 
Her  home  has  been  transformed  into  a  hermitage,  her  children 
sent  away  because  of  their  innocent  prattle,  and  her  husband 
driven  to  seek  refuge  in  other  society  than  that  of  his  home. 
All  this,  in  my  opinion,  because  of  a  lack  of  determination  on 
the  part  of  the  medical  attendant  and  the  proper  execution  of 
methods  of  education  to  the  reinstatement  of  health  at  the 
time  best  indicated.  How  apparent  the  benefits  to  have  been 
derived  from  orificial  philosophy  in  this  case,  and  yet  when  I 
tell  you  that  one  of  our  best  surgeons  did  "all  round"  orificial 
work,  and  did  it  as  well  as  could  have  been  done,  and  that 
she  still  remains  in  the  condition  I  have  depicted,  your  natural 
inquiry  will  surely  be,  Why?  The  answer  is  easy.  Operated 
on  at  her  home,  taken  from  the  table  and  put  back  into  the 
same  bed,  coddled  by  the  same  relatives,  attended  by  the  same 
nurses,  surrounded  by  the  same  environments,  she  could  not 
possibly  be  other  than  the  same  fault-finding,  unreasonable, 
complaining,  unhappy,  sick  individual.  This  could  not  be 
otherwise,  and  yet  if  you  were  to  ask  the  surgeon  who  did  the 
work  for  the  cause  of  failure  he  would  more  than  likely  charge 
the  result  to  failure  of  orificial  principles  and  allow  his  fail- 
ure to  stand  in  condemnation  of  orificial  philosophy. 

These  are  but  two  of  the  many  cases  that  we  meet  every 
day.  Such  observations  are  not  by  any  means  infrequent,  yet 
I  think  you  will  all  agree  orificial  treatment  combined  with 
reason  in  after-treatment  should  have  cured  them  both,  and 
that  it  failed  simply  because  it  was  expected  to  do  more  than 
any  close  observing  reasonable  surgeon  would  dare  to  have 
asked  any  other  form  of  treatment  to  do. 


ORIFIC'IAL    SURGERY.  211 

Thus  we  find  orificial  philosophy  hampered  in  its  possi- 
bilities, charged  with  incompetency  and  continuously  dis- 
credited by  those  who  should  know  more  of  its  requirements, 
think  more  of  its  demands  and  be  more  just  in  their  criticism. 
In  these  two  simple  and  markedly  apparent  cases  we  have 
proof  of  the  necessity  of  a  better  knowledge  of  all  matters  per- 
taining to  the  demands  of  the  treatment  in  whose  success  we 
are  most  interested.  Realizing  our  past  shortcomings,  let  us  all 
be  more  careful,  more  painstaking,  always  alert  for  obstruct- 
ive causes  and  earnest  in  the  defense  of  orificial  principles. 

With  discretion  in  selecting  eases,  judgment  in  applying 
methods  and  consideration  in  after-treatment  principles,  the 
confirmation  of  experience  will  ever  be  most  favorable. 

CHAPTER  XXVIII. 


SURGICAL  DUTIES  OF  THE  GENERAL  PRACTITIONER. 


E.   H.   PRATT,   M.    D. 


Regardless  of  the  multiplication  of  specialties  in  the  prac- 
tice of  medicine  by  far  the  greater  number  of  practitioners 
must  necessarily  be  all-round  men.  Especially  is  this  true  of 
those  who  practice  in  the  smaller  cities  and  towns  and  in  the 
country.  In  medical  meetings  and  medical  literature  the  gen- 
eral practitioner  may  suffer  neglect,  because,  in  the  first  place, 
he  is  exceptionally  modest  and  unobtrusive,  and  in  the  second 
place,  much  that  he  would  be  inclined  to  speak  or  write  about 
would  seem  commonplace  in  comparison  with  the  exhaustive 
and  technical  dissertations  of  specialists.  And  yet  the  all- 
round  man  always  has  been,  is  and  always  will  be,  the  ideal 
doctor,  the  man  who  is  supposed  to  know  a  little  of  everything, 
but  not  everything  of  anything.  While  the  increasing  intelli- 
gence of  the  general  public  demands  a  higher  grade  of  all 
forms  of  medical  service,  the  people  as  a  whole  still  look  up  to 
and  depend  upon  their  family  doctor  as  their  very  best  friend 
and  safest  advisor  upon  all  topics  connected  with  their  physi- 
cal well  being. 


212  ORIFIG'IAL   SURGERY. 

It  is  useless  for  the  specialist  to  aspire  to  the  influential 
position  occupied  in  the  family  circle  by  the  general  prac- 
titioner. The  specialist  is  respected  in  his  specialty,  but  how- 
ever much  he  may  know  of  other  things  confidence  in  his 
opinion  stops  with  his  professed  knowledge,  and  only  as  the 
family  physician  indorses  whatever  he  says  or  does  outside  of 
his  own  professed  line  of  work  does  his  opinion  inspire  confi- 
dence. Such  always  has  been,  is  now  and  ever  will  be  the 
case.  The  all-round  man,  the  general  practitioner,  the  level 
headed,  evenly  balanced  and  universally  intelligent  doctor  of 
medicine  who  can  deliver  women  and  cure  the  children,  who 
can  guide  his  patients  safely  through  all  forms  of  acute  dis- 
orders, and  has  something  to  suggest  for  those  who  are  chron- 
ically ill,  regardless  of  disease  type,  is  the  doctor,  the  ideal 
medical  man,  dear  to  the  hearts  of  the  people,  and  the  best  and 
most  perfect  representative  of  the  practice  of  medicine.  He 
is  something  of  a  diagnostician  and  something  of  a  prescriber; 
he  is  something  of  a  chemist  and  something  of  an  anatomist 
and  physiologist;  he  is  something  of  an  electrician  and  some- 
thing, whether  he  recognizes  it  or  not,  of  a  psychologist;  he  is 
something  of  a  medical  man,  but  also  something  of  a  surgeon. 

This  assertion  is  purposely  framed  in  the  present  tense. 
Time  was  within  the  memory  of  us  all  when  the  family  doc- 
tor could  get  on  quite  satisfactorily  with  a  little  knowledge 
of  surgery,  but  that  time  is  now  gone  by  and  the  general  prac- 
titioner of  today,  while  he  must  know  more  of  drugs  and  chem- 
icals and  diseases  generally,  must  also  know  more  of  surgery 
than  his  predecessor. 

One  of  the  most  important  qualifications  for  the  general 
practitioner  is  a  full  appreciation  of  his  own  personal  limita- 
tions. He  should  have  knowledge  enough  of  all  departments 
of  medicine  and  surgery  to  make  him  fully  alive  to  any  situ- 
ation in  which  he  is  placed,  and  if  he  finds  his  own  personal 
knowledge  of  any  difficulty  he  may  encounter  is  inadequate 
for  its  successful  solution,  he  must  be  wise  enough  to  immedi- 
ately recognize  his  own  deficiencies  and  supplement  them  with 
such  advice  from  special  workers  as  his  case  may  stand  in 
need  of. 


OEIFIC1AL   SURGERY.  213 

The  surgical  knowledge  demanded  of  an  up-to-date  prac- 
titioner has  greatly  increased  of  late  years.  To  be  sure  while 
technicalities  have  greatly  multiplied  many  of  these  are  non-es- 
sential and  can  be  safely  omitted ;  but  the  fundamental  princi- 
ples of  modern  surgery  should  be  thoroughly  mastered  by  ev- 
ery family  practitioner.  These  now  include  not  only  a  knowl- 
edge of  fractures  and  dislocations  and  their  proper  treat- 
ments, of  inflammations  and  neoplasms  and  the  sequences  and 
significance,  but  also  of  modern  bacteriology  and  pathology. 
It  is  no  longer  to  the  credit  of  any  practitioner  of  medicine, 
regardless  of  his  distaste  for  surgical  practice,  to  ignore  or 
refuse  to  recognize  the  germ  theory  of  disease.  However 
much  he  may  prefer  to  limit  his  practice  to  the  prescribing  of 
drugs,  he  is  criminally  negligent  of  his  position  of  high  trust 
as  the  family  guardian  of  health  if  he  neglects  to  give  due  and 
practical  recognition  to  the  surgical  growth  of  the  last  few 
decades  of  surgical  study.  Personally  he  may  feel  an  aversion 
to  the  lancing  of  an  abscess,  and  so  far  he  is  not  to  be  blamed, 
but  it  is  his  business  to  recognize  the  existence  of  an  abscess, 
appreciate  the  importance  of  its  proper  surgical  treatment 
and  as  early  as  possible  call  for  whatever  surgical  help  his 
case  may  stand  in  need  of  to  guide  it  to  a  successful  issue. 

Were  it  not  for  the  fact  that  sins  of  omission  are  of  equal 
magnitude  to  those  of  commission  the  responsibilities  of  the 
general  practitioner  would  be  greatly  lessened.  But  he  has  no 
right  to  be  ignorant  of  the  surgical  necessities  of  his  patients, 
and  it  is  his  plain  duty  in  case  he  is  not  himself  a  practical  sur- 
geon, to  supplement  his  own  deficiencies  with  adequate  assist- 
ance. In  other  words,  he  must  be  possessed  of  sufficient  knowl- 
edge to  recognize  surgical  cases  whenever  they  are  entrusted 
to  his  keeping,  and  either  give  them  the  surgical  attention 
called  for  in  person  or  direct  them  where  to  go  for  it.  Major 
surgical  operations  should  never  be  essayed  by  a  man  in  the 
general  practice  of  medicine  except  in  emergency  eases,  where 
the  circumstances  render  such  practice  unavoidable.  It  is  all 
right  for  the  general  practitioner  who  is  something  of  a  sur- 
geon, to  repair  lacerations  of  the  cervix  and  perineum,  to  un- 
dertake the  dilatation,  curettement,  and  packing  of  the  uterine 


214  ORIFIG'IAL   6URGERY. 

cavity,  to  operate  for  the  removal  of  hemorrhoids,  pockets  and 
papilla?,,  to  evacuate  superficial  pus  cavities  and  treat  burns, 
scalds,  fractures,  and  dislocations,  but  it  is  not  right  for  the 
general  practitioner  to  assume  the  responsibility  of  operating 
upon  rectal  fistulas  or  strictures,  to  perform  hysterectomies  or 
laparotomies,  to  resect  joints  or  amputate  limbs,  to  trephine 
skulls  or  meddle  with  caries  of  the  spine  or  other  deep  seated 
bones,  to  attack  chains  of  enlarged  lymphatic  glands  or  en- 
eurisms,  to  operate  upon  the  kidneys  or  bladder,  to  attempt 
the  extirpation  of  deep  seated  tumors  or  evacuate  deep-seated 
abscesses.  And  this  chiefly  for  two  reasons:  The  first  one  is 
that  his  community  would  not  be  liable  to  forgive  him  for  dis- 
astrous results  from  surgical  procedure  regardless  of  the  skill 
exhibited  or  the  general  merits  of  the  case,  for  a  single  surgical 
disaster  might  ruin  his  good  name,  which  long  years  of  service 
had  established  for  him  in  his  community;  and  however  com- 
petent he  may  be  to  render  skilled  surgical  service,  he  can- 
not afford  to  hazard  his  general  reputation  by  assuming  heavy 
and  unnecessary  responsibilities  in  a  single  case.  The  other 
reason  is  that  it  would  scarcely  be  possible  for  one  whose  time 
was  mainly  spent  in  the  general  practice  of  medicine  to  ob- 
tain sufficient  practice  in  the  handling  of  major  surgical  cases 
to  become  an  expert,  and  he  would  do  neither  his  patient  nor 
himself  justice  in  reckle'ssly  assuming  a  role  he  was  not  well 
schooled  to  fill. 

There  is  less  danger,  however,  of  a  general  practitioner 
undertaking  too  great  surgical  responsibilities  than  there  is 
in  his  overlooking  needed  expert  surgical  work  for  his  patrons. 
His  tendency  to  rely  upon  mere  prescribing  for  the  cure  of 
chronic  cases  is  his  great  weakness,  and  consequently  the  one 
which  should  be  chiefly  guarded  against. 

Aside  from  the  great  surgical  progress  instituted  by  the 
establishment  of  the  germ  theory  of  disease,  the  times  in  which 
we  have  lived  have  disclosed  the  marvelous  fact  that  for  what 
used  to  be  considered  chronic  medical  cases  there  is  now  a 
most  radical,  efficient  and  satisfactory  surgical  cure.  Obsti- 
nate cases  of  chronic  rheumatism,  dyspepsia,  nervous  prostra- 
tion, spinal  irritation,  headaches,  eczema,  bronchitis,  paraly- 


ORIFIG1AL   SURGERY.  215 

sis.  and  other  forms  of  severe  and  persisting  organic  and  tis- 
sue disturbance  in  all  their  various  types  have  shown  them- 
selves easily  amenable  to  a  peculiar  surgical  procedure,  which 
has  clone  more  to  solve  the  problem  of  chronic  disease  for  the 
human  race  than  has  yet  been  appreciated  by  the  profession 
in  general.  Of  this  great  fact  the  general  practitioner,  of  all 
others,  should  be  made  aware.  The  surgical  work  called  for 
in  such  cases  involves  in  the  majority  of  instances  little  suf- 
fering and  small  risk  of  life,  and  is  so  startling  and  effective 
and  phenomenally  satisfactory  as  to  deserve  universal  recog- 
nition and  employment  in  well  selected  cases.  To  be  ignorant, 
careless,  or  indifferent  to  this  great  surgical  help  in  the  treat- 
ment of  chronic  diseases  generally  is  not  to  the  credit  of  any 
general  practitioner  of  the  present  time. 

I  have  reference  now  to  what  is  commonly  known  as  ori- 
ficial  surgery.  This  type  of  surgical  procedure,  by  means  of 
which  the  general  nutrition  of  the  entire  body  and  all  its  or- 
gans can  be  influenced  is  based  upon  universally  recognized 
anatomical  and  physiological  facts,  and  its  practicality  is  no 
longer  a  matter  of  conjecture.  By  orificial  measures  the  sleep- 
ing energies  of  the  body  can  be  wakened,  reactive  power  can 
be  aroused,  improved  capillary  circulation  can  be  universally 
established,  and  an  impetus  given  to  the  restoration  of  health 
in  all  forms  of  chronic  diseases  in  a  more  certain,  permanent, 
speedy  and  in  every  way  satisfactory  manner  than  can  be  fur- 
nished by  any  other  known  remedial  agent.  Thousands  of  the 
advanced  medical  thinkers  of  the  age  have  put  the  orificial 
philosophy  to  test  now  for  many  years,  and  the  result  is  its 
permanent  establishment  as  a  powerful  remedial  factor  in  the 
history  of  medicine.  Its  establishment  in  reality  will  mark  an 
era  in  the  treatment  of  chronic  diseases. 

It  is  not  the  purpose  of  this  paper  to  discuss  in  detail  the 
orificial  philosophy  or  the  surgical  measures  by  which  the  ori- 
ficial thought  is  put  in  practice,  but  rather  to  merely  call  at- 
tention to  the  matter  and  remind  the  general  practitioner  that 
the  chronic  cases  which  baffle  his  prescribing  skill  and  refuse 
to  respond  satisfactorily  to  other  more  commonly  recognized 
measures  at  his  command  are  unquestionably  candidates  for 


216  ORIFICIAL   SURGERY. 

orificial  work,  and  this  fact  should  always  be  borne  in  mind 
and  for  the  sake  of  his  own  reputation  and  the  good  ol  his 
patients  should  be  made  use  of  in  times  of  need.  Every  gen- 
eral practitioner  should  master  the  principles  of  orificial  sur- 
gery, should  see  to  it  that  the  children  which  he  delivers  be  not 
permitted  to  suffer  from  adherent  foreskins  and  hoods  of  the 
clitoris,  from  pockets  and  papillae  and  simpler  forms  of  rectal 
troubles — for  children  do  have  rectal  troubles  fully  as  fre- 
quently as  they  suffer  from  derangements  of  the  eyes,  ears, 
nose  or  throat,  and  preventive  work  in  the  pelvic  region,  which 
has  in  mind  the  release  of  terminal  nerve  fibres  of  the  sympa- 
thetic system  from  undue  impingement,  is  the  most  important 
mesaure  by  far  known  to  medical  men  in  the  sphere  of  pre- 
ventive medicine.  As  we  live,  develop,  recover  and  maintain 
health  and  life  by  means  of  the  sympathetic  nerve,  let  us  by 
all  means  relieve  its  accessible  fibres  from  all  undue  impinge- 
ment and  the  nerve  waste  thereby  involved,  and  thus  permit 
the  natural  life  forces  to  have  full  sweep  in  performing  their 
bodily  functions.  This  is  the  sole  purpose  of  the  orificial 
thought,  and  it  is  serviceable  not  only  in  the  cure  of  the 
chronically  sick  but  also  in  the  prevention  of  disease. 

The  surgical  duties  of  the  general  practitioner  could  be 
treated  much  more  exhaustively  with  profit  and  still  not  half 
the  truth  be  told,  but  short,  suggestive  papers  are  best  for 
society  purposes,  and  enough  has  already  been  said  to  serve 
the  purpose  for  which  this  paper  was  intended. 

CHAPTER  XXIX. 


NERVE   IMPINGEMENT   IN  OPERATIVE   SURGERY. 


E.   H.   PRATT,   M.   D. 


They  say  that  a  human  being  has  two  minds — the  con- 
scious and  the  unconscious  or,  as  Hudson  calls  them,  the  ob- 
jective and  the  subjective. 

Granting  this  to  be  true,  it  is  easily  demonstrable  that  the 
objective  or  conscious  mind  is  the  animating  principle  of  the 


ORIFIGIAL   SURGERY.  217 

cerebro-spinal  system,  and  that  the  subjective  or  the  uncon- 
scious mind  in  a  like  manner  vitalizes  the  sympathetic  nervous 
system.  The  conscious  mind,  which  animates  the  cerebro- 
spinal  system,  receives  impressions  from  the  outer  world  and 
echoes  back  its  judgments  through  the  agency  of  the  afferent 
and  efferent  nerves.  By  the  afferent  nerves  it  sees,  hears, 
smells,  tastes  and  feels.  By  means  of  the  efferent  nerves  what- 
ever the  conscious  mind  wills  and  thinks  can  be  transferred 
into  physical  expression.  These  nerves,  or  telegraph  wires, 
of  the  cerebro-spinal  system  touch  at  their  distal  ends  the  sur- 
faces and  tissues  of  the  body,  and  at  their  proximal  ends  com- 
municate with  the  gray  matter  of  the  brain  and  cord.  No  con- 
scious sensations  reach  the  ego  from  the  world  of  sense  except 
as  they  are  transmitted  along  cerebro-spinal  nerves,  and  no 
action  of  the  voluntary  muscles  is  accomplished  except  as  com- 
mands emanating  from  the  gray  matter  are  carried  to  striated 
or  voluntary  muscular  fibres  by  means  of  cerebro-spinal  nerve 
filaments. 

In  a  corresponding  manner  is  the  unconscious  or  sub- 
jective mind  provided  with  a  nervous  apparatus  called  the 
sympathetic  system,  by  means  of  which  it  receives  at  its  cen- 
tral stations,  or  ganglia,  bodily  reports  of  the  wants  and  con- 
ditions of  the  various  organs  and  tissues,  and  from  which  it 
dictates  perpetually  the  unceasing  activity  of  the  involuntary 
muscles. 

All  of  the  activities  of  the  body  which  are  not  chemical 
are  accomplished  by  tubular  structures,  some  small  and  some 
large ;  the  sweat  and  sebaceous  glands  of  the  skin,  the  race- 
mose glands  and  simple  follicles  of  the  mucous  membrane,  the 
salivary  glands  and  the  pancreas,  the  gall  ducts  and  the  geni- 
to-urinary  tracts,  the  blood-vessels,  bronchial  tubes,  lym- 
phatics, and  the  alimentary  canal,  each  and  all  of  them  owe 
their  activity  to  coatings  of  the  involuntary  muscular  fibres, 
whose  action  is  dominated  by  the  sympathetic  nervous  sys- 
tem, the  blood-vessels  being  the  only  exception,  and  yet  not 
an  exception,  for  the  peristaltic  action  of  the  blood-vessels  is 
influenced  by  the  sympathetic  nerve,  although  not  exclusively 
— the  motor  influence  from  the  cerebro-spinal  system  joining 


218  ORIFIC'IAL   SURGERY. 

that  of  the  sympathetic,  thus  forming  a  combination  of  in- 
fluences from  both  nervous  systems  for  the  control  of  the 
circulation. 

The  sympathetic  nervous  system,  like  the  cerebro-spinal, 
has  both  afferent  and  efferent  nerves.  By  means  of  the  af- 
ferent nerves  bodily  wants  and  conditions  are  made  known 
to  the  nerve  centers.  It  is  by  the  efferent  nerves  that  the  in- 
voluntary muscular  fibers  are  kept  in  operation.  The  sympa- 
thetic nervous  system,  like  the  cerebro-spinal,  listens  to  both 
harmonies  and  discords,  to  joyful  and  distressing  communica- 
tions, is  thrilled  by  delightful  inspirations  or  benumbed  by 
shock,  by  its  system  of  telephone  or  telegraph  wires  called 
nerves.  There  is  this  difference,  however,  in  the  alarm  cry 
of  the  two  systems:  When  alarming  reports  come  from  the 
outer  world  to  the  cerebro-spinal  centers  and  the  harmony  of 
its  domain  is  seriously  disturbed,  they  express  their  discom- 
fort in  the  language  of  pain,  while  the  alarm  cry  of  the  sym- 
pathetic system  is  told  in  the  form  of  functional  derangements. 
By  means  of  repeated  intercommunications  the  two  nervous 
systems  can  be  mutually  cognizant  of  each  other's  operations, 
and  aid  or  antagonize  each  other  in  their  daily  work,  as  they 
are  harmonious  or  discordant.  The  conscious  mind  can  be 
terrorized  by  suggestions  of  danger  from  the  offices  at  the 
distal  ends  of  its  wires,  and  the  unconscious  mind  may  refuse 
to  sympathize  with  the  alarm  and  perform  its  functions  per- 
fectly, regardless  of  the  consternation  prevailing  throughout 
the  cerebro-spinal  system.  On  the  other  hand,  the  unconscious 
mind  can  be  badly  demoralized  by  irritations  conveyed  to  the 
nerve  centers  along  its  afferent  nerves  and  the  functions  over 
which  it  presides  be  seriously  disturbed  and  the  conscious 
mind,  although  perfectly  aware  of  the  mischief  going  on,  may 
refuse  to  heed  the  distress  of  its  companion  sovereign. 

Perfect  specimens  of  humanity,  in  which  the  conscious 
and  unconscious  minds  work  in  unison,  are  indeed  rare  and 
have  little  use  for  doctors.  Our  business  is  with  those  whose 
house  is  divided  against  itself. 

The  foregoing  anatomical  facts  have  an  important  bear- 
ing in  the  consideration  of  nerve  impingement  m  operative 


ORIFICIAL    SURGERY.  219 

procedures  from  the  simple  fact  that  the  nerves  of  either  sys- 
tem are  through  trains  and  that  the  communications  which 
pass  along  them,  either  from  the  world  of  matter  to  the  world 
of  mind,  or  from  the  world  of  mind  to  the  world  of  matter, 
are  sent  from  their  extremities  and  not  in  their  continuity. 
Especially  is  this  true  of  the  cerebro-spinal  nerves.  If  an  ul- 
timate nerve  filament  of  the  cerebro-spinal  system  be  micro- 
scopically examined  it  will  be  found  to  consist  of  a  central 
thread,  or  axis  cylinder,  which  is  the  nerve  proper,  an  insu- 
lating medium  more  or  less  fatty  in  its  nature,  called  the  white 
substance  of  Schwann,  and  an  enveloping  tubular  sheath  of 
membrane  called  by  some  the  neurilemma,  in  each  case  the  in- 
sulation extending  the  entire  length  of  the  filament  from  the 
brain  substance  at  one  end  to  its  terminus  in  the  tissues  at 
the  other  end.  At  its  two  extremities  only  is  the  axis  cylinder 
exposed  and  sensitive  to  impressions.  The  distal  terminals  of 
the  sensory  or  afferent  nerves  of  the  cerebro-spinal  system  are 
located  chiefly  in  the  integument,  and  are  very  thickly  placed 
in  the  papillary  layer  of  the  cutis  vera.  This  is  why  injuries 
of  the  surface  of  the  body,  as  burns  and  lacerations,  are  pain- 
ful and  dangerous  from  shock  in  proportion  to  the  amount  of 
skin  surface  involved  rather  than  to  the  depth  of  the  injury, 
for  alarming  intelligence  from  a  chorus  of  nerves  can  produce 
more  bodily  apprehension  than  can  be  set  up  by  a  few  indi- 
vidual fibers. 

The  terminals  of  the  motor  or  efferent  nerves  of  the  cere- 
bro-spinal system  are  found  chiefly  in  the  voluntary  muscles, 
and  the  main  effect  of  injury  to  them  is  loss  of  muscular  pow- 
er. The  nerves  of  the  sympathetic  system  differ  from  those 
of  the  cerebro-spinal  in  that  they  possess  no  axis  cylinder,  ap- 
pearing like  prolongations  of  gray  matter  enclosed  in  a  deli- 
cate neurilemma.  For  this  reason,  while  communications  pass 
along  them  from  the  two  extremities  of  the  nerves,  the  im- 
pingement of  the  nerve  trunks  in  continuity  is  more  disastrous 
than  in  the  case  of  the  cerebro-spinal  nerves.  When,  a  nerve 
of  either  system  is  severed  or  ruptured,  or  excessively  im- 
pinged upon,  communications  to  the  nerve  centers  may  be 
made  from  the  point  of  injury  or  impingement,  but  not  so  dis- 


220  ORIFIG1AL   SURGERY. 

tinctly  as  from  the  nerve  terminals,  because  of  the  protection 
extended  by  the  neurilemma,  and  in  the  case  of  the  cerebro- 
spinal  system  by  the  insulating  medium  of  the  white  substance 
of  Schwann. 

Operative  surgery  involves  not  only  the  making  but  the 
closing  of  wounds.  The  making  of  wounds  is  always  prescribed 
by  the  necessities  of  the  case.  In  the  extirpation  of  tumors 
and  foreign  bodies,  in  the  excision  of  joints  and  the  removal 
of  dead  bone,  and  in  the  evacuation  of  abscesses  and  the  open- 
ing of  cavities,  the  nature  and  extent  of  the  wound  involved 
is  prescribed  by  the  nature  of  the  work  to  be  accomplished.  It 
must  be  long  enough  and  deep  enough  and  convenient  enough 
to  be  adequate  to  its  purpose.  But  it  is  in  the  closure  of 
wounds  that  there  is  great  room  for  improvement,  and  it  is 
the  object  of  the  present  paper  to  call  the  attention  of  sur- 
geons to  the  necessity  of  a  more  extended  respect  for  the  ana- 
tomical considerations  which  we  have  briefly  outlined  than  has 
been  their  wont  in  the  closing  of  wounds  after  all  forms  of 
operative  procedure. 

The  surgical  habits  of  today  are  seriously  at  fault  in  that 
they  involve  unnecessary  pain,  shock,  and  thereby  endanger 
not  only  the  success  of  the  operation  itself  but  the  general 
prosperity  of  the  patient. 

In  behalf  of  suffering  humanity  I  beg  leave  to  plead  for  a 
reform  of  surgical  practice  in  two  particulars,  viz. :  The  co- 
aptation  of  all  wounded  skin  surfaces  by  subcutaneous  stitch- 
ing, and  the  avoidance,  as  far  as  possible,  of  the  nerve  impinge- 
ment involved  in  the  ligation  and  clamping  of  tissues  en  masse. 

Let  us  then  first  consider  the  subcutaneous  closure  of  sur- 
face wounds.  When  a  stitch  which  pierces  the  skin  upon  both 
sides  is  tightened,  it  impinges  steadily  and  severely  upon  the 
terminal  ends  of  the  afferent  or  sensitive  nerve  fibers  of  the 
cerebro-spinal  system  which  have  their  distribution  within  its 
grasp.  The  distress  occasioned  is  not  only  a  source  of  general 
discomfort  and  of  more  or  less  consternation  to  the  conscious- 
ness of  the  patient,  but  involves  also  an  undue  activity  in  the 
underlying  voluntary  muscles,  for  the  afferent  nerves  are  close- 
ly associated  with  the  corresponding  efferent  ones,  thus  plac- 


ORIFICTAL    SURGERY.  221 

ing  muscular  action  and  surface  sensation  in  sympathetic  as- 
sociation. A  subcutaneous  stitch  which  will  fully  as  satisfac- 
torily accomplish  the  coaptation  of  the  skin  margins  dispenses 
with  much  of  this  discomfort,  owing  to  the  fact  that  a  moder- 
ate impingement  of  the  nerve  trunks  is  materially  less  painful, 
and  consequently  less  harmful,  than  an  equal  impingement  of 
nerve  terminals.  In  amputations,  in  resections,  in  abdominal, 
thoracic  and  cranial  work,  and  in  perineal  work,  a  subcutane- 
ous stitch  is  equally  effective  with  the  present  practice  of  skin 
piercing  and  pinching,  and  it  is  attended  with  so  much  less 
pain,  shock  and  general  discomfort  to  the  patient  that  it 
should  become  a  universal  practice. 

There  are  two  ways  of  accomplishing  subcutaneous  stitch- 
ing. One  is  longitudinally,  and  the  other  perpendicularly,  to 
the  wounded  surfaces.  The  stitch  should  puncture  the  deeper 
layers  of  the  cutis  vera,  care  being  taken  merely  to  avoid 
wounding  the  papillary  layer.  The  deep  layers  of  the  skin  are 
sufficiently  tense  and  substantial  to  afford  all  the  support  ne- 
cessary for  the  closure  of  wounds.  The  subcutaneous  method  of 
stitching  has  the  advantage  also  of  causing  less  interference 
with  the  capillary  circulation  of  the  parts  involved,  and  there- 
fore insures  a  better  healing  than  is  obtained  by  the  common 
method  of  coapting  wounded  skin  surfaces  by  skin  piercing 
and  impingement. 

Now  as  to  the  avoidance  of  nerve  impingement  by  the 
ligation  and  clamping  of  tissues  en  masse. 

There  are  five  exceedingly  bad  surgical  habits  which  seem 
to  me  to  need  correction.  They  need  correction  because  they 
are  clumsy,  unsurgical,  unscientific  and  cruel  in  their  nature, 
unsatisfactory  and  frequently  disastrous  in  their  effects,  and 
because  they  are  wholly  unnecessary.  The  sooner  they  are 
abandoned,  therefore,  the  better  it  will  be  for  both  surgeons 
and  their  patients.  In  all  cases  they  involve  the  severe  im- 
pingement, either  by  clamp  or  ligature,  of  large  masses  of 
tissues  and  their  contents,  nerves  and  all,  en  masse;  in  all 
oases  they,  therefore,  produce  unnecessary  shock  to  the  pa- 
tient, and  in  all  cases  they  endanger  the  vitality  of  the  con- 


222  ORIFICIAL  SURGERY. 

stricted  stump  and  tend  to  the  formation  of  sloughs,  thus  fa- 
voring secondary  hemorrhage  and  septic  conditions. 

The  five  bad  surgical  habits  referred  to  are: 
1st.     The  deep  sutures  so  frequently  employed  in   closing 
abdominal  wounds,  in  the  operation  for  laceration  of  the  per- 
ineum, and  in  the  American  operation. 

2nd.  The  ligation  of  the  omentum  where  its  amputation 
is  demanded. 

3rd.  The  ligation  in  segments  or  en  masse  of  the  broad 
ligaments,  or  of  the  uterus  itself,  or  of  both,  in  the  removal  of 
ovarian  and  fibroid  tumors  by  the  abdominal  route. 

4th.  The  clamping  or  ligating  of  the  broad  ligaments  in 
vaginal  hysterectomy. 

5th  and  last.     The  removal  of  hemorrhoids  by  ligation. 

Let  us  briefly  consider  them  in  the  order  mentioned. 

First  bad  surgical  habit:  The  deep  sutures  so  frequently 
employed  in  closing  abdominal  wounds  and  in  the  operation 
for  laceration  of  the  perineum  and  in  the  American  operation. 

The  practice  of  employing  deep  sutures  in  the  closure  of 
abdominal  wounds — and  by  deep  sutures  I  mean  those  which 
penetrate  the  entire  thickness  of  the  abdominal  walls  on  either 
side  —  I  am  glad  to  say  is  no  longer  universally  practiced,  but 
nevertheless  it  is  sufficiently  in  vogue  to  deserve  brief  mention 
in  the  present  connection.  Deep  abdominal  stitches  afford  no 
added  security  to  the  wound,  interfere  with  the  nutrition  of 
the  part,  add  materially  to  the  danger  and  the  suffering  of  the 
patient  by  the  added  pain  and  shock  which  they  involve,  in- 
vite inflammatory  action,  are  in  no  way  essential  to  recovery, 
and  in  every  way  are  mischievous  and  undesirable.  They  not 
only  unduly  pinch  and  distress  the  outer  integument  within 
their  grasp,  but  also  the  peritoneal  surfaces,  and  their  grasp 
upon  the  recti  muscles  induces  muscular  spasm  without  ex- 
cuse for  it. 

In  closing  abdominal  wounds  in  the  median  line  it  is  suf- 
ficient to  coapt  the  wounded  margins  of  the  peritoneum,  the 
severed  sheaths  of  the  recti  muscles,  and  by  subcutaneous  li- 
gation the  severed  margins  of  the  integument  in  three  sep- 
arate continuous  sutures.  Where  the  abdominal  wound  has 


ORIFICTAL    SURGERY.  223 

been  made  laterally  and  it  has  been  found  necessary  to  sever 
muscular  tissue,  in  such  cases  it  will  be  necessary  to  coapt  the 
severed  muscular  fibers.  But  in  no  case  should  muscles  be 
stitched  when  their  fibers  have  not  been  severed. 

In  closing  a  perineum  deep  stitches  are  necessary  to  coapt 
the  posterior  extremities  of  the  sphincters  vagina?  and  the 
transversus  perinei  muscles,  but  only  two  or  three  stitches  are 
necessary  and  these  should  not  include  the  skin.  The  needle 
should  enter  the  wounded  surface  close  to  the  margin  of  the 
skin  upon  one  side,  pass  through  the  extremities  of  the  mus- 
cles to  be  reunited,  and  find  its  exit  close  to  the  skin  on  the  op- 
posite side,  so  as  to  avoid  skin  impingement.  Subcutaneous 
stitching  can  be  relied  upon  for  the  surface  coaptation.  One 
reason  for  failure  to  secure  satisfactory  results  in  the  American 
operation  is  that  the  stitching  employed  is  not  only  of  the 
variety  of  skin  puncturing  and  pinching,  which  we  have  al- 
ready considered,  but  that  the  stitches  are  frequently  so  deep 
as  to  pierce  the  fibers  of  the  external  sphincter  muscle,  there- 
by inducing  spasmodic  contraction  of  the  same  and  tearing 
the  ma  'gins  of  the  wound  apart  or,  in  cases  where  healing 
takes  place,  inducing  a  clumsy  and  strictured  condition  which 
requires  subsequent  correction.  Subcutaneous  stitching  prac- 
tically solves  the  only  remaining  problem  of  the  American 
operation  and  robs  it  of  its  terrors.  The  pain  following  the 
subcutaneous  stitching  in  the  American  operation  is  so  greatly 
reduced  that  the  patients  seldom  suffer,  sphincter  contractions 
are  avoided,  healing  by  first  intention  is  secured,  and  quicker 
and  more  satisfactory  results  are  thereby  attained. 

The  superiority  of  the  subcutaneous  stitching,  both  in  the 
deep  and  superficial  threads,  is  surprising  both  in  the  healing 
of  the  parts  and  in  the  comfort  of  the  patient. 

Second  bad  surgical  habit:  The  ligation  of  the  omentum 
where  its  amputation  is  demanded. 

It  is  mainly  to  avoid  squeezing  sympathetic  nerve  plexus 
that  the  wadding  together  of  the  omentum,  by  the  application 
of  a  tightly  drawn  ligature,  is  objected  to.  The  hemorrhage 
can  be  easily  controlled  by  a  running  stitch,  which  includes 
each  blood-vessel  in  a  separate  loop  and,  when  it  is  tightened, 


224  ORIFIG1AL   SURGERY. 

ligates  the  blood-vessel  and  successfully  controls  the  hemor- 
rhage without  pinching  the  other  omental  tissues.  This  is  by 
no  means  difficult  of  accomplishment  and  takes  but  a  trifle 
more  time  than  is  required  to  ligate  the  omentum  en  masse, 
and  avoids  undue  nerve  impingement. 

Third  bad  surgical  habit:  The  ligation  in  segments  or  en 
masse  of  the  broad  ligaments,  or  of  the  uterus  itself,  or  of 
both,  in  the  removal  of  ovarian  and  fibroid  tumors  by  the  ab- 
dominal route. 

The  sympathetic  plexuses  of  nerves  inclosed  within  the 
folds  of  the  broad  ligament  are  large  and  correspondingly  in- 
fluential in  the  bodily  economy;  and  whereas  it  is  always  in 
order  to  ligate  blood-vessels  to  control  hemorrhage,  it  is  never 
in  order  to  tie  nerves,  especially  when  it  is  just  as  easy  to  con- 
trol the  hemorrhage  without  doing  so. 

There  are  two  places  on  each  side  of  the  female  pelvis 
where  hemorrhage  is  liable  to  be  encountered  in  the  removal  of 
the  ovaries  and  uterus,  and  these  are  at  the  outer  and  inner 
edges  of  the  broad  ligament,  the  first  place  being  marked  by 
the  point  where  the  fallopian  tube  and  ovary  meet,  and  the 
other  being  situated  just  below  the  angle  of  the  attachment  of 
the  fallopian  tube  to  the  uterine  margin.  The  dissection  of 
the  ovary  and  tube  from  the  broad  ligament  can  be  started  at 
the  outer  extremities  and,  when  the  blood-vessels  are  sev- 
ered, it  is  a  simple  matter  to  secure  them  with  artery  forceps. 
As  the  fallopian  tube  and  the  ligament  of  the  ovary  are  care- 
fully dissected  away,  should  other  blood-vessels  be  encoun- 
tered, it  is  an  easy  matter  to  seize  them  with  forceps.  In  this 
manner  the  dissection  can  proceed  as  far  as  the  uterus,  at 
whose  margins  the  hemorrhage  which  occurs  can  also  be  se- 
cured in  the  same  manner.  A  continuous  suture  can  now  be 
applied  along  the  severed  margins  of  the  broad  ligament,  be- 
ginning at  its  outer  margin,  and  at  every  point  where  an  ar- 
tery forceps  seizes  a  blood-vessel  a  loop  of  the  continuous  su- 
ture can  be  thrown  around  it  sufficiently  tight  to  secure  the 
artery  and  at  the  same  time  coapt  the  wounded  margins  of  the 
broad  ligament,  so  that  no  wounded  surface  shall  be  left  in  the 
peritoneal  cavity.  This  practice  can  be  followed  as  far  as 


ORIFICIAL   SUEGERY.  225 

the  uterus,  at  which  point  one  or  more  additional  loops  of  the 
continuous  thread  will  be  needed  to  secure  the  bleeding  ves- 
sels in  the  grasp  of  artery  forceps.  The  other  side  can  be 
treated  in  a  similar  manner  if  it  is  operated  upon.  The  uterus 
itself,  if  it  is  to  be  removed,  can  be  amputated  on  a  level  with 
the  floor  of  the  pelvis,  or  even  below  the  internal  os,  by  the  flap 
method  without  the  slightest  difficulty.  It  never  bleeds  to  any 
extent,  and  there  is  not  the  slightest  excuse  for  choking  it  with 
a  ligature.  The  margins  of  the  uterine  flaps  can  be  coapted  by 
the  same  threads  which  formed  the  lateral  continuous  sutures 
and,  as  they  meet  in  the  middle,  can  then  be  tied  together.  By 
this  process  ovarian  and  fibroid  tumors,  regardless  of  their 
size,  can  be  easily  and  expeditiously  removed  without  tying 
anything  except  blood-vessels,  securing  even  these  with  loops 
of  the  continuous  thread  which  coapts  the  wounded  margins  of 
the  peritoneum,  and  after  the  work  is  performed  all  the  relics 
of  the  operation  left  in  the  pelvis  are  simply  the  absence  of  the 
organs  and  a  narrow,  uninterrupted  seam  from  the  outer  mar- 
gin of  one  broad  ligament  to  the  outer  margin  of  the  other. 
Of  course,  where  extensive  adhesions  are  present,  modifications 
of  this  procedure  will  be  called  for.  But  there  is  no  excuse  on 
any  occasion  for  the  ligation  or  clamping  of  masses  of  tissue, 
as  is  now  so  commonly  practiced.  The  difference  in  the  de- 
gree of  shock  to  the  patient,  and  the  difference  in  the  degree 
of  health  subsequently  attained  by  this  method  of  securing 
the  stump  and  the  ordinary  methods  in  vogue  is  simply  re- 
markable, and  the  method  just  described  has  so  much  to  com- 
mend it,  and  it  is  so  entirely  free  from  every  objectionable 
feature,  that  there  is  little  excuse  for  the  continuance  of  the 
practice  of  securing  pelvic  pedicles  by  the  old  method  of  either 
clamping  or  ligating  large  masses  of  tissue. 

Fourth  bad  surgical  habit:  The  clamping  or  ligating  of 
the  broad  ligaments  in  vaginal  hysterectomy. 

There  are  many  serious  objections  to  the  employment  of 
either  clamps  or  tissue  ligatures  in  vaginal  hysterectomy.  The 
danger  of  wounding  the  ureters  or  the  intestines  where  ad- 
hesions are  present  is  not  inconsiderable,  nor  is  secondary 
hemorrhage  from  the  sloughing  which  is  usually  induced,  un- 


226  OEIPICTAL   SUEGEBY. 

common;  and,  so  far  as  the  employment  of  clamps  is  con- 
cerned, they  are  liable  to  slip  their  hold  and  fail  of  their  pur- 
pose to  control  the  hemorrhage,  in  addition  to  the  irritation 
and  inflammation  which  they  set  up,  and  the  distress  to  the 
patient  while  they  are  retained  in  position  for  twenty-four  or 
forty-eight  hours.  But  these  and  many  other  objections,  which 
may  fairly  be  urged  against  securing  the  broad  ligaments  in 
the  grip  of  either  clamps  or  ligatures,  do  not  properly  concern 
the  purpose  of  the  present  paper. 

The  great  objection  which  is  our  present  concern,  and  the 
only  one  your  attention  should  be  invited  to  in  the  present 
paper,  is  the  fact  that  when  the  broad  ligaments  are  squeezed 
by  either  clamp  or  ligature  to  so  sufficient  an  extent  as  to  con- 
trol hemorrhage,  not  only  the  blood-vessels  but  all  of  the  in- 
tervening tissues  are  badly  pinched ;  this  means,  aside  from  a 
considerable  expanse  of  peritoneal  surface,  the  large  plexuses 
of  sympathetic  nerve  fibers  which  lie  within  its  folds.  The 
effect  of  excessive  and  protracted  pinching  of  these  important 
plexuses  of  nerves  is  to  induce  severe  functional  disturbance 
not  only  in  the  remaining  pelvic  organs  but  in  all  functions 
of  the  body  that  are  dominated  by  the  sympathetic  nerve,  for 
the  distress  telephoned  by  these  plexuses  to  the  sympathetic 
nerve  centers  creates  a  great  disturbance  of  the  entire  sympa- 
thetic nervous  system. 

The  removal  of  the  uterus  and  its  appendages  in  cases 
where  such  an  operation  is  demanded,  and  in  which  the  va- 
ginal route  is  decided  upon,  can  always  be  accomplished  by 
dissection.  In  fact,  many  cases  are  operable  by  this  method 
that  are  inoperable  by  the  clamp  and  ligature  methods,  and 
hence  there  are  no  operable  cases  which  cannot  be  satisfactor- 
ily handled  by  the  dissection  method.  The  field  of  operation 
is  always  within  view,  and  as  blood-vessels  are  wounded — 
which,  of  course,  is  frequently  the  case — it  is  a  simple  matter 
to  seize  them  with  artery  forceps  and  either  ligate  them  as 
they  are  encountered  or  secure  them  in  the  subsequent  clos- 
ure of  the  wound.  The  details  of  accomplishing  this  will  be 
found  in  another  section  of  this  book,  giving  in  full  the  tech- 
nique of  this  operation.  As  long  as  nerve-pinching  in  vagina! 


OBIFJGIAL,   SURGERY.  227 

hysterectomy  is  both  harmful  and  unnecessary  it  seems  but 
reasonable  to  conclude  that  it  ought  to  be  abandoned. 

Fifth  and  last  bad  surgical  habit:  The  clamping  or  ligat- 
ing  of  hemorrhoids.  Professor  Agnew,  while  holding  a 
college  clinic,  presented  to  the  class  a  case  of  fistula. 
The  man  was  placed  under  the  influence  of  ether  and  the  case 
successfully  operated  upon  and  in  due  time  dismissed.  A  year 
later  the  same  man  presented  himself  to  the  same  clinic,  and 
the  same  man  gave  him  the  same  anesthetic,  and  the  same  sur- 
geon, Professor  Agnew,  proceeded  to  operate  upon  him  for 
hemorrhoids.  The  patient  took  the  anesthetic  just  as  kindly 
as  he  had  done  the  year  previous.  When  he  was  profoundly 
asleep  Professor  Agnew  proceeded  to  remove  the  piles  by  the 
orthodox  process  of  ligation  but,  strange  to  relate,  as  soon  as 
he  tightened  the  ligature  around  the  first  pile  tumor  the  anes- 
thetist called  his  attention  to  the  general  condition  of  the  pa- 
tient, who  had  stopped  breathing  and  was  rapidly  becoming 
cyanotic.  Professor  Agnew  rose  from  his  chair,  observed  that 
the  man  was  breathless  and  rapidly  becoming  pulseless.  Active 
measures  for  his  resuscitation  were  immediately  inaugurated. 
Artificial  respiration  was  practiced  with  the  patient  in  the 
horizontal  position,  and  also  with  the  head  and  shoulders  de- 
pendent. Electricity  and  all  other  means  at  the  command  of 
Professor  Agnew  and  his  assistants  were  employed,  and  proved 
unavailing.  The  man's  spirit  went  out,  and  neither  Professor 
Agnew  himself  nor  any  of  his  attendants  nor  any  of  the  gen- 
tlemen present  seemed  to  think  far  enough  or  know  enough  to 
cut  the  string  which  was  all  this  time  strangling  the  pile  tumor 
and  terminal  filaments  of  the  sympathetic  nerve,  and  by  sym- 
pathetic communication  was  paralyzing  the  action  of  the 
phrenic  and  pneumogastric  nerves.  Professor  Agnew  himself 
clearly  and  carefully  described  the  case  in  all  its  painful  de- 
tails in  a  prominent  medical  journal,  and  yet  I  have  seen  no 
comment  either  in  that  journal  or  in  any  other  upon  the  ig- 
norance manifested  in  this  case  concerning  the  disturbance  to 
the  respiration  which  follows  injury  to  the  rectal  nerves.  The 
death,  was,  of  course,  attributed  to  the  action  of  ether,  and  yet 
the  patient  had  taken  it  safely  the  year  before  and  was  acting 


228  OKIFIGTAL  SURGERY. 

kindly  under  its  influence  at  the  time  of  the  last  operation  un- 
til the  very  moment  at  which  the  ligature  was  applied  about 
the  pile  tumor.  This  point  was  very  carefully  made  by  Pro- 
fessor Agnew  himself  in  his  description  of  the  case,  and  yet  it 
never  occurred  to  him  that  the  ligating  of  the  tumor  had  any- 
thing to  do  with  the  man's  respiration,  and  that  the  cutting 
of  the  string  which  bound  the  tumor,  accompanied  by  slight 
dilatation  of  the  sphincter,  would  have  immediately  restored 
the  man  to  animation. 

This  is  by  no  means  the  only  death  which  has  occurred 
from  the  ligation  of  hemorrhoids  and  which  has  been  attrib- 
uted to  the  action  of  the  anesthetic.  But  aside  from  its  imme- 
diate danger,  the  practice  of  ligating  hemorrhoids  has  no  pos- 
sible excuse  for  existence.  This  method  of  treatment  was  in- 
augurated at  a  period  in  rectal  surgery  when  there  were  no 
proper  instruments  with  which  to  expose  rectal  tissues  and 
place  them  at  the  command  of  the  surgeon.  The  fear  of  hem- 
orrhage in  an  inaccessible  position  was  the  excuse  for  the 
measure.  But  that  excuse  has  long  since  passed  away.  By 
means  of  modern  rectal  instruments  the  rectal  tissues  can  be 
so  thoroughly  brought  into  view  that  the  operating  field  in 
anal  surgery  is  as  perfectly  under  the  observation  and  control 
of  the  surgeon  as  is  any  other  part  of  the  human  body,  and 
there  is  no  longer  the  excuse  of  necessity  to  uphold  the  contin- 
uance of  this  barbarous  practice. 

If  a  tumor  is  to  be  removed  let  it  be  amputated,  and  if  the 
part  bleeds  let  the  blood-vessels  be  secured  by  ligation  if 
necessary,  although  the  fact  is  that  in  hemorrhoidal  work  it 
is  very  rarely  called  for. 

It  is  not  my  purpose  in  the  present  paper  to  consider  the 
various  methods  of  treating  hemorrhoids  and  discuss  their 
comparative  merits,  but  simply  to  protest  against  an  undue 
and  unnecessary  nerve  impingement  in  rectal  work  as  in  all 
other  operative  procedures.  The  nerve  impingement  of  ce- 
rebro-spinal  fibers  may  induce  muscular  contractions,  either 
clonic  or  tonic,  and  is  responsible  for  much  of  the  pain,  irri- 
tability, inflammation,  sepsis  and  death  of  surgical  cases.  The 


OEIFIGLAL   SUBGERY.  229 

nerve  impingement  of  the  sympathetic  system  disturbs  func- 
tions and  lowers  vitality. 

As,  then,  the  impingement,  by  clamps  or  ligatures,  of 
nerve  trunks  of  either  the  cerebro-spinal  or  sympathetic  sys- 
tem in  cases  where  the  shock  which  it  occasions  does  not  im- 
mediately kill,  disturbs,  devitalizes  and  more  or  less  perma- 
nently maims  the  patient  upon  whom  it  is  practiced,  it  should 
in  all  reason  be  eliminated  as  far  as  possible  from  all  sur- 
gical procedures. 


CHAPTER  XXX. 


ABDOMINAL   SECTION  IN  THE   LIGHT   OF  ORIFICIAL 

PHILOSOPHY. 


E.   H.  PRATT,   M.   D. 


Laparotomies  are  performed  by  the  present  generation  of 
surgeons  for  the  relief  of  a  large  variety  of  troubles.  Not 
presuming  to  give  an  exhaustive  list,  let  us  consider  a  few  of 
the  more  common  complaints  for  which  the  operation  is  under- 
taken. It  is  done  for  appendicitis,  acute  and  chronic,  it  is 
done  for  biliary  calculi,  for  gunshot  and  stab  wounds,  for  fib- 
roid and  cancerous  tumors  of  the  omentum  and  female  pelvic 
organs,  for  the  removal  of  diseased  ovaries  and  tubes,  for  ven- 
tral fixation  of  the  uterus,  and  as  a  means  of  diagnosis  some- 
times for  the  general  abdominal  cavity  and  sometimes  for  the 
pelvic  cavity. 

In  the  removal  of  ovaries,  tubes  and  tumors  of  various 
kinds,  the  present  practice  is  to  ligate  or  clamp  all  pedicles 
either  inside  or  outside  of  the  abdomen. 

The  central  thought  in  orificial  surgery  is  to  avoid  the  un- 
due impingement  of  nerve  fibres,  whether  in  a  normal  or  ab- 
normal condition.  This  great  principal  finds  its  application 
not  only  in  treating  the  sphincter  guarded  opening  of  the  body, 
but  wherever  wounds  are  closed  or  stumps  are  treated. 


230  ORIFIG1AL   SURGERY. 

With  this  thought  in  mind,  what  suggestions  have  we  to 
make  to  laparotomists  ?  First,  as  to  the  external  abdominal 
wound.  Is  it  necessary  to  employ  deep  sutures,  which  clutch 
with  a  more  or  less  vise-like  grip  the  sensitive  abdominal  wall, 
including  the  recti  muscles  and  a  large  area  of  skin  surface? 
Does  this  not  cause  unnecessary  contraction  of  muscular  fib- 
res, and  by  choking  the  tissues  produce  an  unnecessary  de- 
gree of  nerve  tension  and  discomfort,  if  not  danger?  If  the 
sheathes  of  the  recti  muscles  were  intact,  the  abdominal  cavity 
would  have  its  normal  protection  so  far  as  the  middle  portion 
of  the  abdominal  wall  is  concerned.  The  peritoneum  has  no 
tendency  to  displacement,  and  as  it  heals  very  quickly  where 
its  edges  are  coapted  a  continous  suture  in  the  peritoneum 
is  all  that  is  required  to  sufficiently  protect  the  peritoneal  in- 
jury; and  as  for  the  integument,  instead  of  clutching  large 
bunches  of  it  in  the  severe  grip  of  a  tightly  drawn  ligature,  it 
is  much  neater,  more  comfortable,  just  as  safe,  and  conse- 
quently more  satisfactory  to  coapt  merely  the  margins  of  the 
integument  by  a  nicely  adjusted  continuous  suture.  By  thus 
stitching  together  the  various  tissues  of  the  abdominal  walls 
separately,  the  surgeon  is  able  to  avoid  all  undue  pinching  of 
the  tissues  and  to  do  away  with  much  of  the  shock  that  fol- 
lows laparotomies. 

In  the  opening  of  the  peritoneum  for  peritonitis,  for  ab- 
scess, for  gall  stones,  for  appendicitis,  or  for  gunshot  or  stab 
wounds,  orificial  surgery  has  nothing  to  suggest  to  general 
surgery,  except  in  the  securing  of  the  abdominal  wound.  It 
is  worthy  of  mention,  however,  that  many  cases  of  appendi- 
citis and  typhlitis  in  the  chronic  form  have  been  to  all  appear- 
ance permanently  and  perfectly  cured  by  orificial  surgery  ap- 
plied to  the  lower  openings  of  the  body.  It  has  been  my 
pleasure  to  handle  a  few  cases  of  abdominal  abscess  in  this 
manner  successfully  without  the  aid  of  laparotomy,  although 
there  are  frequently  recurring  attacks  of  appendicitis;  while 
we  would  suggest  the  employment  of  orificial  surgery  as  a  pre- 
liminary operation,  it  may  be  best  later  on  to  remove  the  of- 
fending appendix  to  avoid  the  possibility  of  future  attacks  of 
acute  inflammation. 


OKIFIC1AL    SURGERY.  231 

In  the  amputation  of  the  omentum  for  cancer  or  other  tu- 
mor, instead  of  ligating  the  omentum  in  sections  and  thus 
doing  violence  to  a  broad  area  of  tissue  freely  ramified  by 
sympathetic  nerve  fibres,  it  would  please  orificialists  to  see  the 
wounded  margins  secured  by  a  continous  suture,  employing  a 
single  turn  of  the  suture,  or,  if  the  operator  prefers,  a  liga- 
ture of  catgut  at  the  bleeding  points  to  secure  the  hemorrhage. 

In  removing  large  ovarian  tumors  we  see  no  reason  for 
ligating  or  clamping  the  broad  ligament,  and  now  that  we  have 
come  to  know  the  harm  of  tying  large  bunches  of  tissue,  and 
the  ease  with  which  the  hemorrhage  can  be  secured  and  the 
wound  excluded  from  the  peritoneal  cavity  by  a  nice  coaption 
of  the  severed  margins  of  the  peritoneum,  we  hope  to  see  this 
improved  method  of  speedily  handling  the  pedicles  of  ovarian 
tumors  universally  adopted  by  laparotomists.  The  same  re- 
mark will  apply  to  those  cases  in  which  the  ovaries  and  tubes, 
although  of  small  size,  are  so  disorganized  as  to  demand  re- 
moval and  the  operator  prefers  to  take  them  away  by  the  ab- 
dominal route. 

In  the  treatment  of  fibroids,  especially  when  they  are  in- 
trauterine  and  intramural,  orificial  surgery  has  an  important 
message  to  send  to  those  who  are  in  the  habit  of  removing 
these  frequent  growths  by  the  way  of  the  abdomen.  If  the  tu- 
mors are  movable  and  no  larger  than  a  foetal  head  weighing 
perhaps  from  one  and  one-half  to  three  pounds,  it  is  much 
more  preferable  to  remove  the  tumors  by  the  vaginal  route 
than  to  take  them  out  through  the  abdominal  section.  It  in- 
volves less  bruising  of  the  peritoneum,  less  handling  of  the  in- 
testines, and  is  in  every  way  the  more  desirable  operation,  es- 
pecially in  view  of  the  manner  of  performing  hysterectomy 
which  orificial  surgery  has  presented  to  the  world.  If  the  tu- 
mor be  too  large,  however,  to  be  removed  by  way  of  the 
vagina,  and  the  abdominal  route  is  decided  upon,  it  chills  the 
blood  of  the  orificialist  to  contemplate  the  unnecessary  squeez- 
ing of  tissues,  the  shock  and  sloughing  with  its  danger  of  sep- 
sis, involved  in  the  methods  at  present  in  vogue  for  accom- 
plishing the  desired  object. 


232  ORIFICIAL   6URGEBY. 

We  will  not  take  the  time  to  rehearse  the  various  methods 
at  present  employed  of  choking  the  broad  ligaments  and  uter- 
ine stump,  for  they  are  all  objectionable,  whether  by  clamp  or 
ligature;  but  simply  offer  as  a  substitute  a  much  more  hu- 
mane, successful  and  at  the  same  time  easier  accomplished 
method  which  has  already  been  described  in  orificial  writings, 
which  has  the  following  points  in  its  favor : 

It  wounds  large  arteries  only  in  occasional  cases,  for 
under  all  circumstances  in  securing  the  patient  against  hem- 
orrhage it  ligates  only  blood-vessels,  and  under  no  circum- 
stances pinches  by  ligature  or  clamp  either  muscular,  areolar, 
peritoneal  or  uterine  tissues,  thus  avoiding  undue  impinge- 
ment of  all  nerve  plexuses,  and  doing  away  with  the  danger 
of  sloughing  of  the  stump  and  leaving  no  wounded  surface  ex- 
posed in  the  peritoneal  cavity.  Much  of  the  danger  from 
shock,  from  inflammation  and  from  blood  poisoning  is  thus 
very  easily  avoided,  and  the  better  way  is  not  more  difficult 
of  accomplishment,  is  not  as  difficult  as  the  more  dangerous 
methods  which  we  are  desirous  of  seeing  abandoned. 

What  has  been  said  of  fibroid  tumors  is  equally  true  of 
cancerous  degeneration  of  the  ovaries,  tubes  and  body  of  the 
uterus.  Whatever  can  be  done  in  this  unfortunate  class  of 
cases  by  opening  the  abdominal  cavity  can  be  better,  more 
thoroughly  and  more  satisfactorily  accomplished  by  respect- 
ing the  suggestion  already  made  than  in  any  other  way.  For 
those  who  rely  on  the  use  of  clamps  and  ligatures  to  choke  off 
tissues  which  they  fear  will  bleed,  the  cases  which  are  sessile, 
either  ovarian  and  tubal  or  uterine  troubles,  will  be  found  im- 
practicable for  operation.  These  can  be  easily  and  success- 
fully handled  by  the  method  we  are  presenting. 

It  will  always  be  necessary,  in  all  probability,  to  make  ex- 
ploratory incisions  in  the  abdominal  cavity  for  diagnosing  ab- 
dominal difficulties  located  above  the  dome  of  the  pelvis,  and 
in  many  cases  for  pelvic  troubles  themselves,  for  there  is  a 
large  class  of  pelvic  difficulties  in  women  that  can  be  better 
examined  and  treated  by  the  vaginal  route,  which  at  the  pres- 
ent time  are  subjected  to  the  abdominal  section.  Where  the 
uterus  is  movable,  an  easier,  safer  and  more  satisfactory  ex- 


ORIFIC1AL   SURGERY.  233 

animation  of  the  lower  pelvis  can  be  made  by  entering  the 
peritoneal  cavity  either  in  front  or  behind  the  uterus  than 
can  be  made  from  above.  Small-sized  ovarian  tumors,  and 
the  tubes  in  cases  of  pyosalpinx,  are  more  easily  and  safely  re- 
moved by  way  of  the  vagina  than  through  the  abdominal 
opening.  This  class  of  cases,  formidable  in  their  nature,  which 
it  is  difficult  to  handle  satisfactorily  from  above,  can  be 
reached  with  a  degree  of  success  from  below.  I  refer  to  those 
cases  where  a  local  sub-acute  peritonitis  has  succeeded  in  glue- 
ing the  ovaries  to  the  walls  of  the  pelvis,  and  so  completely 
covering  them  up  as  to  make  their  detection  from  above  a 
matter  of  extreme  difficulty.  Such  cases  are  usually  bilateral, 
and  the  removal  of  the  uterus  is  invariably  essential  to  a  cure. 
With  this  organ  removed,  and  a  T-forceps  securing  a  grip  up- 
on the  upper  edge  of  the  broad  ligament  which  marks  the  situ- 
ation of  the  fallopian  tube,  the  tubes  and  ovaries  can  be  read- 
ily located  and  extracted  from  their  bed  of  inflammatory  de- 
posits. In  such  cases  the  ovaries  are  friable  and  can  be  taken 
away  only  in  fragments.  But  the  importance  of  the  removal, 
we  believe,  is  not  sufficiently  appreciated  by  surgeons  who  are 
not  familiar  with  the  orificial  philosophy  and  the  story  it  tells 
of  the  mischief  accomplished  by  the  pinching  of  nerve  fibres 
by  contracting  tissues. 

In  the  reports  of  laporotamies  as  published  in  current  lit- 
erature one  frequently  reads  of  cases  in  which,  as  the  ovaries 
were  imbedded  and  showing  signs  of  inflammation,  they  are 
permitted  to  remain  unmolested.  To  an  orificialist,  however, 
who  understands  that  the  cicatricial  tissue  is  perpetually  con- 
tracting with  time,  and  that  when  it  involves  an  ovary  it  is 
squeezing  that  organ  tighter  and  tighter  as  the  days  go  by, 
occasioning  more  and  more  sympathetic  nerve  waste,  and  do- 
ing more  and  more  violence  to  the  harmony  of  the  entire  body, 
it  seems  of  more  importance  to  remove  these  imbedded  ovar- 
ies, whether  they  be  large  or  small,  and  release  the  terminal 
nerve  fibres  which  cover  this  surface  from  their  unnatural  con- 
striction in  this  cobweb  of  perpetually  tightening  fibres  than 
as  though  the  organs  presented  a  much  more  magnified  form 
of  pathology  and  were  free  to  expand  as  their  unnatural  pro- 


234  ORIFIGTAL   SUEGEBY. 

portions  increased.  Ovaries  of  this  nature  can  be  excavated 
from  their  living  tomb  through  the  vagina,  where  it  would  be 
very  difficult  and  perhaps  dangerous  to  attempt  their  removal 
by  abdominal  section.  As  to  ventral  fixation  of  the  uterus,  for 
the  correction  of  retroflexion  it  may  be  the  best  way,  but  for 
picked  cases  Alexander's  operation  and  one  or  two  retroflexion 
operations  already  published  in  orifieial  writings  seem,  for 
many  reasons  unnecessary  to  mention  in  this  article,  prefer- 
able. 


SECTION  V. 


The  Rectum. 


ORIFKflAL    SURGERY.  237 


CHAPTER  XXXI. 


NEUROSES  OF  THE  RECTUM  AND  ANUS. 


H.    L.    TOWNSEND,    M.    D. 


The  rectal  and  anal  neuroses  are  so  widespread,  so  simple 
and  obvious  at  times,  yet  so  complex  and  remote  at  others, 
that  we  should  not  be  surprised  to  find  in  them  a  subject  for 
deep  thought  and  thorough  investigation.  The  subject  is  an 
obscure  one  and  has  never  been  exhaustively  studied  but  by 
a  limited  number,  viz.:  Ultzman,  Matthews,  Kelsey,  White- 
head  and  Pratt,  the  latter  of  whom  has  brought  out  more 
clearly  than  all  the  others  the  reflexes  and  the  pathological 
conditions  growing  out  of  such  nerve-waste. 

Etiology.  It  may  be  set  down  at  the  outset  that  the 
rectum,  like  other*  parts  of  the  intestinal  canal,  and  the  stom- 
ach, bladder,  urethra,  etc.,  has  complex  motor  secretory  func- 
tions which  are  capable  of  derangement  through  the  nervous 
system,  and  reacting  on  the  nervous  system  when  so  deranged. 
It  is  unnecessary  to  cite  in  analogy  the  profound  impression 
which  even  slight  gastric  disturbance  may  make  upon  the  brain 
and  its  functions,  causing  vertigo,  neurasthenia,  spasms,  and 
even  confirmed  epilepsy,  or  the  violent  urethral  chill  and  ac- 
companying pyrexia  which  the  most  careful  introduction  of  a 
catheter  causes  in  some  cases. 

Speaking  again  by  analogy,  if  the  existence  of  phimosis 
in  childhood  can  cause  serious  reflex  disturbances,  it  requires 
no  argument  to  show  that  an  irritation  of  anus  or  rectum  may 
also  cause  disturbance.  Nervous  reaction  to  all  bowel  troubles 
is  profound  in  a  degree. 

In  the  rectum,  however,  or  in  the  terminal  portions,  we 
find  what  does  not  exist  in  any  other  part  of  the  intestines — a 
full  supply  of  sensory  nerves.  Hence  we  have  added  to  the 
sympathetic  system  the  possibility  of  sensory  neuroses,  of 
which  the  peculiar  disease  known  as  fissure  of  the  rectum  is  a 
typical  example.  Before  considering  the  different  varieties  of 


238  ORIFICIAL   SURGERY. 

rectal  neuroses,  it  may  be  well  to  inquire  in  general  what  de- 
gree of  severity  and  importance  these  have  as  compared  with 
the  neuroses  of  other  parts  of  the  body.  Are  they,  like  those 
of  the  stomach,  capable  of  inducing  disease  in  the  brain  and 
nerve  centers  by  long-continued  irritation?  Can  mere  rough 
handling  cause  dangerous  or  fatal  collapse  as  in  the  case  of  the 
bladder?  Can  radiating  pains  or  general  malaise  and  debility 
such  as  follow  disease  of  the  ovaries  be  traced  to  local  disease 
of  the  rectum?  These  questions  can  be  answered  in  the  af- 
firmative in  a  large  number  of  cases.  In  many  directions  they 
are  similar,  in  others  less  severe,  and  still  in  others  are  ob- 
scure and  baffling,  yet  not  the  less  real  and  troublesome. 
Structural  changes  whether  acute  or  chronic,  classed  as  neu- 
rasthenia, and  marked  by  abnormal,  exalted,  reflex  excitement, 
are  prone  to  affect  the  rectum.  The  causes  to  which  we  al- 
lude are  mainly  those  that  produce  other  neuroses,  flushing, 
vertigo,  incontinence  or  retention  of  urine.  Vesical  tenesmus, 
etc.,  are  most  common  in  anemic  persons  in  early  life.  Over- 
study  or  business  anxiety,  great  fear,  etc.,  may  often  be  found 
to  have  brought  such  individuals  to  a  state  of  extreme  prostra- 
tion. It  cannot  be  disputed  that  there  is  a  class  of  such  cases 
analogous  to  that  in  which  impotence,  spermatorrhea,  etc., 
are  the  chief  troubles,  where  the  rectum  and  anus  are  the  seat 
of  neuroses.  Fear  or  shocks  to  the  nervous  system  often  pro- 
duce involuntary  movements  from  the  bowels;  or  on  the  other 
hand,  constipation  may  follow  great  mental  strain  of  any  kind. 
Some  obscurity  must  be  admitted  to  exist  as  to  the  exact  ner- 
vous mechanism  involved  in  these  symptoms.  Through  the 
hypogastric  plexus  of  the  sympathetic  nervous  system  which 
is  in  intimate  relation  with  the  sacral,  the  uterine  or  vesical 
and  lumbar  spinal  nerves,  the  anus,  rectum,  and  genito-urinary 
organs  are  intra-related.  (Echard.) 

Not  only  do  they  react  on  each  other  as  when  operations 
on  the  rectum  cause  retention  of  urine,  but  they  are  both  sub- 
ject to  the  same  impression  from  the  central  nervous  system. 

Vasomotor  neuroses  of  the  lower  bowel  have  only  been 
studied  in  the  last  few  years;  and  to  Prof.  Pratt  is  due  the 
honor  of  its  demonstrative  action,  both  curatively  and  patho- 


ORIFIG'iAL   SU'RGEBY.  239 

logically.  An  example  of  its  effect  is  demonstrated  very  for- 
cibly in  at  least  fifty  per  cent,  of  all  cases  by  the  use  of  the 
rectal  speculum,  under  partial  or  full  expansion,  by  its  arterial 
depression  which  as  soon  as  removed  disappears.  Alteration 
of  blood  pressure  is  a  natural  result  of  their  disturbance. 

The  region  of  the  anus  is  peculiarly  rich  in  sensory  nerves, 
while  the  upper  portions  are  nearly  devoid  of  sensibility. 
Hence  diseases  such  as  ulceration  in  the  upper  portion  are 
painless;  while  small  lesions  about  the  anal  verge  are  acutely 
painful.  The  nerve  distribution  about  Hilton's  white  line 
which  is  so  plain  to  be  seen  under  full  dilatation  is  where  the 
sensory  ends  and  the  sympathetic  begins.  Hyperesthesia  of 
the  anus  will  be  invariably  found  to  be  present  where  there  is 
local  irritation  from  hemorrhoids,  proctitis,  fissures,  etc.,  while 
a  normal  rectum  will  bear  the  insertion  of  a  small  speculum  or 
the  oiled  finger  without  pain;  where  slight  disease  will  make 
the  rectum  so  sensitive  that  an  internal  examination  is  nearly 
impossible  and  if  persisted  in  will  cause  pain  for  several  days. 
In  this  state  of  hyperesthesia  which  is  common  in  the  rectum, 
the  part  is  the  most  sensitive  in  the  whole  body,  not  excepting 
the  eye,  urethra  or  bladder.  It  is  therefore  not  unaccountable 
that  the  element  of  pain  is  so  prominent  in  all  rectal  troubles. 

Closely  associated  with  hyperesthesia  is  neuralgic  trouble 
of  the  rectum  and  anus.  Undoubtedly  cases  are  found  in  which 
severe  pain  in  the  lower  bowel  is  accompanied  by  some  local 
lesion.  This  may  or  may  not  be  associated  with  motor  neu- 
roses such  as  tenesmus  of  the  bladder  or  rectum.  It  is  some- 
times a  concomitant  of  brain  or  spinal  disorders,  sometimes  it 
is  purely  local. 

Purely  nervous  forms  of  pruritis  ani  are  not  very  uncom- 
mon, and  such  are  the  most  stubborn  cases  to  cure.  Medicines 
and  local  applications  show  but  meagre  results;  but  a  thor- 
ough dilatation  and  removing  all  irritating  pathological  con- 
ditions will  restore  a  normal  condition  or  will  put  the  patient 
in  a  condition  where  medication  will  avail.  Reflex  pain  is  a 
common  form  of  rectal  neuroses  in  a  bad  case  of  hemorrhoids, 
wounds  or  injuries  to  the  anus  or  severe  proctitis.  Local  pain 
is  often  less  severe  than  the  radiating  in  parts  more  remote. 


240  ORIFICEAL   SURGERY. 

Severe  lumbar  pain  is  a  constant  symptom  of  rectal  disease, 
particularly  of  the  pile-bearing  inch,  which  was  very  marked 
in  a  case  I  operated  on  the  8th  inst.  The  patient  located  the 
pain  at  the  upper  part  of  the  sacrum,  and  thought  the  disease 
was  higher  up  than  at  the  verge.  Examination  failed  to  find 
any  trouble  above  the  pile-bearing  inch.  At  that  point,  within 
the  grasp  of  the  sphincters  were  two  large  hemorrhoids  which 
I  removed.  When  the  patient  was  fully  out  from  under  the 
anesthetic  he  said  the  dull  ache  was  gone.  I  simply  cite  this 
case  as  one  example  out  of  many  in  my  experience.  When 
there  is  a  great  irritation  of  the  anal  membrane,  a  pain  like 
that  of  cystitis,  with  or  without  vesical  tenesmus  and  retention 
is  usually  felt.  Like  that  of  cystitis  the  pain  is  often  referred 
to  the  glans  penis,  and  is  accompanied  by  a  frequent  mic- 
turition. Its  cause  is  explained  by  the  arrangement  of  the  ner- 
vous supply  above  mentioned. 

Motor  neuroses  of  the  rectum  and  anus  are  intimately  con- 
nected with  the  sensory.  Painful  tenesmus  of  the  bowels  in 
dysentery  may  exist  without  local  disease  of  any  kind.  The 
oft  repeated  evacuations  create  congestion,  and  the  rectum 
tries  to  expel  its  own  mucous  membrane.  It  is  probable  that 
in  a  normal  condition  it  is  empty,  except  just  before  defeca- 
tion, and  is  not  physiologically  in  any  sense  a  receptacle  for 
retaining  fecal  matter.  Rectal  spasm  is  a  constant  symptom 
of  proctitis,  but  it,  like  neuralgia,  may  exist  without  local 
disease.  Spasm  of  the  sphincter  alone  is  also  found  as  a  local 
expression  or  a  general  neurotic  condition,  and  as  a  result  of 
fissure,  piles,  etc. 

On  account  of  the  large  sensory  nerve  supply  at  the  anus, 
there  is  much  more  nerve  reflex  disturbance  in  spasm  of  the 
sphincter  than  in  rectal  spasm,  i.  e.,  prostration,  faintness,  etc. 

Motor-urinary  reflexes  are  among  the  most  obvious  and 
easily  explained  effects  of  irritation,  disease,  or  surgical  in- 
terference about  the  rectum. 

The  pudic  branch  of  the  sacro-coccygeal  plexus  is  a  com- 
mon source  of  the  inferior  and  medium  hemorrhoidal  nerves 
which  innervate  both  the  sphincters  ani,  and  the  lower  third 


OEIFIC1AL    SU-BGEEY.  241 

of  bladder  and  sphincter  vesicae.     Spasm  of  both  is  a  natural 
and  usual  result  of  irritation. 

In  the  female  the  vagina  receives  its  nerve  supply  from  the 
same  branches;  and  in  a  large  majority  of  rectal  and  vaginal 
operations  temporary  retention  of  urine  occurs. 

There  is  a  constant  tendency  to  vesical  spasm  in  rectal 
trouble  and  vice  versa.  The  normal  evacuations  also  tend  to 
occur  simultaneously,  entirely  apart  from  the  will.  Enuresis 
in  children  is  to  be  explained  partly  by  reference  to  the  same 
nervous  mechanism.  Before  the  age  of  one  year  there  is  no 
involuntary  resistance  of  the  sphincters;  and  discharge  of 
urine  and  feces  take  place  whenever  there  is  the  slightest  ex- 
pulsive force.  Control  of  the  sphincters  ani  begins  at  the  end 
of  the  first  year ;  control  of  the  urinary  sphincter  not  until  the 
age  of  two  years  (Ultzman),  or  after  dentition.  After  this  age 
bed  wetting  in  children  should  be  considered  abnormal.  The 
reason  for  its  description  here  is  that  it  is  amenable  to  treat- 
ment. While  in  itself  a  local  bladder  neurosis,  pure  and  sim- 
ple, it  furnishes  an  excellent  illustration  of  the  favorable  im- 
pressions that  may  be  made  upon  the  nerves  through  the  nerves 
of  the  rectum  and  anus.  All,  or  nearly  all  of  the  old  writers 
attributed  the  cause  of  bed  wetting  to  functional  disturbance 
of  the  nerve  supply  of  the  vesical  sphincter.  No  one  supposed 
that  this  affection  was  in  any  way  connected  with  disease  of 
the  rectum,  until  Professor  Pratt  thoroughly  demonstrated  it 
by  orificial  methods.  Did  indirect  treatment  of  rectal  irrita- 
tion relieve  and  cure  vesical  diseases  of  that  nature?  If  rectal 
reflexes  are  so  profound  when  disturbed,  why  not  take  advan- 
tage of  them  to  impress  the  nerve  center  favorably  in  a  great 
variety  of  nervous  troubles.  By  dilating  the  sphincters  and 
smoothing  off  all  pathological  conditions  as  near  as  may  be,  it 
flushes  the  capillary  circulation  and  that  in  time  improves  the 
nutritive  function,  nerves,  and  tissue,  starting  the  patient  on 
the  upward  road  to  health.  A  single  dilatation  is  not  enough 
in  all  cases  to  arouse  the  sluggish  nervous  system  from  its 
slumbers;  but  the  repetition  with  the  use  of  the  rectal  plug  is 
sufficient,  if  the  patient  has  had  first  a  thorough  dilatation  un- 


242  OBIFICIAL   SURGERY. 

der  an  anesthetic.  As  soon  as  all  soreness  is  gone,  begin  the 
use  of  the  plug  at  intervals  of  every  other  night,  leaving  it 
from  ten  minutes  to  half  an  hour. 

CHAPTER  XXXII. 


RECTAL  SURGERY  CONSIDERED  IN  ITS  RELATION  TO 
GENERAL  SURGERY. 


E.   H.   PRATT,   M.   D. 


The  general  principles  underlying  all  pathology  are  uni- 
versal in  their  application,  whatever  tissues  of  the  body  may 
be  involved.  Cases  calling  for  surgical  attention  differ  in  no 
wise  so  far  as  the  principles  upon  which  their  repair  is  based 
are  concerned,  from  those  which  are  able  to  dispense  with  sur- 
gical attention.  Capillary  circulation,  cell  destruction,  removal 
of  the  debris,  cell  proliferation  and  a  supply  of  material  to 
accomplish  this  are  considerations  of  universal  application  in 
all  forms  of  physical  disorder,  medical  and  surgical.  Surgical 
practice  is  always  an  apology  for  better  work.  It  is  destructive 
in  its  character,  severe  in  its  application,  and  should  always  be 
appealed  to  as  a  last  resort  for  the  relief  of  human  suffering. 
While  it  is  a  matter  of  deep  consolation  to  be  provided  with 
this  last  resort,  to  be  possessed  with  the  ability  to  save  the 
whole  by  the  sacrifice  of  a  part,  it  is  also  to  be  lamented  that 
the  beginnings  of  destructive  changes  cannot  be  detected  in 
sufficient  time  and  that  our  knowledge  of  other  remedial  meas- 
ures is  not  fully  adequate  to  keep  the  machinery  of  life  in  har- 
monious action  without  permitting  it  to  become  so  disarranged 
as  to  demand  surgical  interference. 

In  the  present  state  of  development  of  the  medical  pro- 
fession, however,  surgeons  are  in  constant  demand  and  sur- 
gical practice  is  honorable  and  indispensable.  The  possibili- 
ties of  relief  from  surgical  praitices  are  constantly  increasing, 
and  I  am  glad  to  feel  that  the  general  tendency  of  surgical 
thought  is  toward  conservatism. 


ORIFIC1AL   SURGERY.  243 

There  is  a  fascination  about  wounding  and  healing,  about 
drawing  blood  and  stopping  it,  about  cutting  away  disease  and 
leaving  health,  that  combines  in  its  elements  of  attraction  the 
innate  love  of  mathematics,  of  punishment  of  the  guilty,  of 
reward  of  the  good,  of  curiosity  and  heroism.  Operations  upon 
the  dead  are  not  classified  as  surgical  proceedings;  they  are 
nothing  but  anatomical  dissections.  The  human  house  has 
opened,  its  inhabitant  has  moved  out,  disintegration  is  immi- 
nent, and  to  dub  a  mere  anatomist  as  a  surgeon  would  be  a 
misnomer.  The  practice  of  surgery  presumes  the  existence  in 
its  subject  of  proper  reactive  power,  of  a  vital  force,  of  life, 
of  a  soul,  element,  or  whatever  you  may  choose  to  call  it.  When 
this  spark  of  vitality  is  flickering  like  a  dying  ember,  when  it 
is  so  far  gone  as  to  be  beyond  recall,  no  reputable  surgeon 
would  be  unmanly  enough  to  plunge  his  scalpel  into  the  almost 
lifeless  flesh. 

The  first  question  which  a  surgeon  is  called  upon  to  decide 
in  a  given  case,  therefore,  is  whether  or  not  his  patient  still 
retains  sufficient  tendency  of  life  to  enable  him  to  sustain  the 
meditated  attack  upon  his  vitality.  Surgical  measures  involve 
shock  and  presume  upon  reaction.  Is  the  patient  in  question 
still  sufficiently  alive  to  rebound,  or  will  the  severity  of  the 
proposed  treatment  hasten  the  exit  of  the  vital  spark?  All 
chronic  pathology  implies  depleted  energy.  There  is  a  nat- 
ural tendency  in  human  nature  towards  health  and  harmony, 
and  when  a  human  system  permits  the  continuous  presence  in 
any  part  of  a  morbid  condition,  it  is  simply  because  it  can't 
help  it.  So  that  this  bit  of  pathology,  wherever  it  may  be 
found,  is  an  expression  not  only  of  local  mischief,  but  also  of 
deep  depreciation  in  the  tone  of  reactive  power  of  the  entire 
body. 

A  disorganized  joint,  too  dilapidated  for  repairs,  is  tax- 
ing a  poor  organ  beyond  endurance.  If  the  patient  yet  retains 
a  considerable  degree  of  vigor  an  operation  upon  the  joint,  re- 
moving the  debris  and  establishing  drainage  may  be  under- 
taken with  full  confidence  that  the  general  health  of  the  pa- 
tient will  be  improved  and  the  harmony  of  the  rest  of  the 
body  restored  by  applying  correct  surgical  principles  to  the 


244  OBIFIG1AL    SURGERY. 

sick  joint.  But  if  the  appeal  to  the  surgeon  has  been  late,  if 
the  life  of  the  patient  is  at  so  low  an  ebb  that  the  very  process 
of  repairing  the  joint  will  involve  greater  shock  than  the  pa- 
tient is  able  to  react  from,  the  conscientious  surgeon  will  re- 
fuse to  shorten  an  earthly  existence  by  a  too  bold  interference 
and  simply  say  it  is  too  late,  and  do  what  he  can  to  make  the 
remaining  days  as  endurable  as  possible. 

The  question  which  I  shall  propose  for  your  discussion 
is,  are  there  any  means  heretofore  neglected  by  employing 
which  the  general  health  of  a  patient  can  be  improved;  by 
wfiich  his  stock  of  vitality  can  be  increased ;  by  which  his  re- 
active power  will  be  so  materially  added  to  as  to  increase  the 
possibility  of  major  surgery,  or  possibly  dispense  with  a  con- 
siderable portion  of  it?  And  shall  not  only  present  the  ques- 
tion for  your  consideration,  but  take  radical  grounds  in  the 
affirmative.  Yes,  there  are  measures  which  have  been  neglect- 
ed, which  if  employed,  will  bestow  upon  any  patient,  surgical 
or  medical,  increased  vitality,  which  will  render  all  major  op- 
erations less  dangerous  and  more  helpful,  and  which  will  dis- 
pense with  the  necessity  of  quite  a  percentage  of  major  sur- 
gical work  which  would  otherwise  be  impossible  or  imperative. 

The  thought  to  which  I  shall  attract  your  attention  in  this 
direction  has  been  employed  by  hundreds  of  doctors  upon  thou- 
sands of  patients,  and  has  won  for  itself  such  widespread  rec- 
ognition as  to  absolutely  demand  from  all  would-be  surgeons, 
as  well  as  doctors,  careful  consideration  and  appreciation. 

If  you  will  consider  that  the  lower  openings  of  the  body 
are  in  such  close  sympathy  and  communication  that  they  suf- 
fer together  and  must  get  well  together ;  that  rectal  disease  ex- 
ercises a  profound  effect  upon  sexual  conditions,  and  that 
sexual  conditions  influence  the  condition  of  the  rectum;  and  if 
you  will  take  it  for  granted  that  the  sexual  system  has  been 
placed  in  repairs,  I  can  then  discuss  the  mutual  relations  be- 
tween these  rectal  conditions  and  major  surgery  with  a  clear 
conscience.  A  healthy  rectum  is  essential  to  normal  peristal- 
tic action,  to  a  normal  capillary  circulation,  to  general  vi- 
vacity, to  the  presence  of  a  substantial  reactive  power.  The 
converse  of  this  is  also  true.  In  weakened  peristaltic  action, 


ORIFIC1AL   SURGERY.  245 

enfeebled  circulation,  lowered  vitality  and  deficiency  of  re- 
active power  there  will  always  be  found  upon  examination 
some  form  of  rectal  pathology,  more  especially  in  the  last 
inch  of  the  organ. 

To  employ,  then,  major  surgery  upon  an  enfeebled  sub- 
ject without  recognizing  and  removing  the  nerve  waste  oc- 
casioned by  the  concomitant  pathology,  is  an  omission  on  the 
part  of  the  surgeon  which  demands  severe  censure,  and  from 
now  on  will  receive  it.  A  surgeon  has  no  right  to  be  behind 
the  times;  he  has  no  right  to  refuse  to  recognize  the  progress 
of  the  age  in  which  he  lives ;  and  when  a  new  thought  has  gone 
far  enough  to  be  a  mattei  jf  special  study  by  thousands  of 
physicians  and  surgeons,  to  be  introduced  into  the  curricu- 
lum of  a  number  of  medical  colleges  in  good  standing,  and  to 
be  practiced  as  a  means  of  cure  in  many  sanitariums,  *  *  * 
it  has  gone  beyond  the  dictum  of  any  one  man  or  set  of  men, 
and  has  so  completely  won  its  right  to  public  recognition  as  to 
stamp  the  surgeon  who  refuses  to  give  such  of  his  patrons  as 
may  need  it  the  benefit  of  its  teachings,  as  a  back  number  in 
the  medical  profession,  and  one  wholly  unfit  to  assume  the 
great  responsibilities  of  surgical  practice. 

First  of  all,  the  surgeon  must  appreciate  the  effect  pro- 
duced upon  respiration  and  circulation  by  dilating  the  anal 
sphincters.  It  is  of  untold  importance  in  patients  who  behave 
badly  under  an  anesthetic,  and  is  the  greatest  means  for  re- 
suscitation from  collapse  caused  either  by  the  anesthetic,  loss 
of  blood,  or  surgical  shock. 

The  general  surgeon,  then,  should  always  have  a  bivalve 
rectal  speculum  at  his  command  whenever  a  patient  is  anes- 
thetized for  any  purpose  whatsoever,  perfectly  regardless  of 
the  condition  of  the  rectum.  In  cases  of  great  debility,  where 
a  capital  operation  is  called  for,  even  if  the  surgeon  does  not 
endorse  all  of  the  methods  recommended  by  orificial  surgeons 
for  securing  increased  nutrition  and  vitality,  he  cannot  con- 
scientiously refuse  to  give  his  patient  the  benefit  of  a  uni- 
versal flushing  of  the  capillaries  which  can  always  be  secured 
by  dilating  the  sphincters,  which  may  be  thoroughly  done  if 
the  patient  be  anesthetized,  and  which  may  be  easily  done 


246  ORIFIG1AL  SURGERY. 

without  an  anesthetic  to  a  sufficient  extent  to  stimulate  per- 
manently and  materially  the  weakened  forces  of  a  delicate  pa- 
tient. The  surgeon  should  not  forget  also,  in  anesthetizing  a 
patient,  that  in  cases  which  have  inhaled  large  quantities  of 
the  anesthetic  employed  without  the  proper  stupifying  effect, 
that  rectal  dilatation  will  materially  assist  in  producing  nar- 
cosis and  save  the  patient  from  the  unhappy  after-conse- 
quences of  a  too  free  use  of  the  anesthetic  material.  A  gen- 
eral surgeon  should  recognize  the  fact  that  when  the  capillary 
circulation  has  been  thoroughly  re-established  by  skillful  rec- 
tal work,  many  serious  affections  of  the  deep-seated  tissues 
and  organs  of  the  body  which  otherwise  would  require  the  em- 
ployment of  major  surgery,  will  disappear  if  sufficient  time  be 
allowed  for  the  improved  circulation  to  accomplish  its  legiti- 
mate and  reliable  reparative  process. 

The  general  surgeon  should  also  recognize  the  fact  that 
in  all  cases  of  pathology  calling  for  major  surgical  procedure, 
his  patient  upon  examination  will  present  some  form  of  rectal 
pathology,  which,  if  allowed  to  remain  uncorrected,  will  han- 
dicap peristaltic  action  throughout  the  entire  body,  and  ma- 
terially interfere  with  the  success  of  his  work.  The  proper 
course  for  the  general  surgeon  to  pursue,  therefore,  when  con- 
templating an  operation,  is  either  to  correct  all  rectal  trou- 
bles as  a  preparatory  proceeding,  allowing  some  weeks  ^i 
months  to  elapse,  as  the  case  may  be,  before  proceeding  with 
the  major  work;  so  as  to  permit  his  patient  to  receive  the  full 
benefit  of  whatever  rectal  work  the  case  may  have  required; 
or  in  cases  where  the  patient  is  reasonably  vigorous  and  pre- 
sents but  minor  rectal  pathology  after  performing  the  major 
operation  called  for,  he  should  immediately  give  his  attention 
to  the  rectum  and  correct  whatever  he  finds  out  of  order  in 
that  locality  before  permitting  the  patient  to  awaken  from  the 
influence  of  the  anesthetic.  Whatever  rectal  work  may  be 
done  in  a  given  case,  it  should  always  be  supplemented  by  such 
after-treatment  as  will  ultimately  secure  for  the  patient  a  di- 
latable anus  free  from  all  forms  of  irritation. 

Rectal  surgery  will  thus,  when  its  importance  is  properly 
appreciated,  become  the  hand-maid  and  chief  ally  of  major 


ORIFIC1AL   SURGERY.  24? 

surgery;  and  its  employment,  although  it  will  not  always  dis- 
pense with  major  surgical  proceedings,  will  materially  dim- 
inish their  number,  render  more  successful  those  which  are  un- 
avoidable, thus  decreasing  mortality  and  adding  materially  to 
the  longevity  and  healthfulness  of  the  races  of  men. 

I  see  by  referring  to  the  papers  presented  at  the  various 
State  societies  of  the  present  year,  that  the  profession  are  be- 
ginning to  realize  that  we  live  by  peristaltic  actions;  that 
these  are  dependent  for  their  vigor  upon  the  great  sympa- 
thetic nerve;  that  the  wastes  and  supplies  of  the  sympathetic 
nerve  are,  therefore,  legitimate  and  essential  objects  of  care- 
ful consideration  and  study  by  all  members  of  the  medical 
profession.  Surgeons  as  well  as  doctors  must  recognize  this 
recent  advance  in  medical  science  and  take  advantage  of  its 
principles. 

It  would  not  be  proper  in  the  present  paper  to  descend 
from  the  general  principles  to  details,  either  of  method  or 
pathology,  but  my  object  will  have  been  fully  accomplished  if 
I  succeed  in  arousing  the  members  of  this  Surgical  Associa- 
tion to  a  realization  of  the  fact  that  there  is  a  relation  of  great 
importance  always  existing  between  rectal  and  general  sur- 
gery, and  enlisting  their  hearty  co-operation  in  a  careful  study 
and  consideration  of  the  subject. 

We  must  not  carry  conservatism  to  the  point  of  obstinacy. 
We  must  not  ignore  newly  found  facts — if  they  are  facts.  We 
must  not  stand  still  when  the  rest  of  the  world  is  moving.  We 
owe  it  to  our  patients  and  to  ourselves  to  be  honest,  earnest 
and  safely  progressive. 

CHAPTER  XXXIII. 


THE  TOILET  OF  THE  RECTUM. 


T.   J.   APPLETON,   M    D. 


The  use  of  water  in  the  toilet  of  the  rectum  is  of  very 
great  importance  and,  with  very  few  exceptions,  should  be 
used  by  every  one,  young  or  old. 


248  ORIFIG1AL   SUKOEEY. 

The  method  employed  is  very  simple.  A  common  foun- 
tain syringe  is  the  best  instrument,  and  tepid  water  the  best 
temperature.  The  rectum  should  be  douched  with  a  small 
quantity  of  water  while  in  a  sitting  posture,  immediately  after 
stool,  repeated  two  or  more  times,  not  allowing  the  water  to 
pass  into  the  colon.  This  can  be  avoided  by  passing  off  the 
water  at  the  first  urging.  Then  dry  the  parts  with  some  soft 
paper  or,  better  still,  a  wet  cloth. 

This  procedure  is  to  be  employed  in  fairly  normal  cases 
and  as  a  hygienic  measure,  just  as  we  would  care  for  the 
teeth  or  any  other  part  of  the  body;  but  for  obvious  reasons 
this  is  of  more  importance. 

The  rectum,  physiologically  considered,  is  a  repository 
for  nothing;  consequently,  when  anything  remains  in  it,  harm 
results,  and  after  stool  there  will  always  be  some  adherence, 
if  not  considerable  accumulation,  both  externally  and  in- 
ternally. That  externally  is  always  removed,  but  internally 
very  rarely.  The  internal  adherence  causes  harm,  but  the  ex- 
ternal, if  allowed  to  remain,  would  not  cause  constitutional 
harm.  The  one  appeals  to  the  cerebro-spinal  nerves,  the  other 
to  the  sympathetic.  This  procedure  employed  in  normal  con- 
ditions of  the  rectum  will  prevent  most  all  of  the  rectal  path- 
ology, and  therefore  resulting  constitutional  troubles.  Used 
in  abnormal  states,  it  reduces  congestions  locally  and  at  dis- 
tant points;  but  to  obtain  the  best  results  in  the  latter  class, 
the  temperature  and  amount  of  water  must  be  varied  to  suit 
the  case.  Usually  it  is  best  after  cleansing  the  rectum  to  in- 
troduce the  tube  and  allow  water  to  pass  in  and  out  at  the 
same  time,  using  simply  a  common  tube  instead  of  a  recurrent, 
thereby  getting  the  action  of  the  water  and  temperature  on 
the  last  inch.  It  is  a  very  valuable  assistance  in  preparing 
cases  for  radical  operations,  and  also  in  the  subsequent  treat- 
ment of  them,  and  renders  annoying  cases  simple  and  kind, 
cold  or  hot,  or  both  kinds  of  water  can  be  used  in  neurasthenic 
cases  in  the  same  manner  with  excellent  results.  Rectal  and 
colon  flushing  are  of  great  benefit  in  diarrhea  of  any  kind, 
and  will  cure  very  many  cases  without  any  other  means  being 
employed. 


ORIFIC1AL    SURGERY.  249 

Dr.  Hall  has  recommended  a  method  of  colon-flushing  that 
has  done  a  great  amount  of  good,  but  it  goes  too  far  in  non- 
pathologic  cases,  and  cases  where  the  colon  is  normal  but  the 
rectum  is  diseased. 

The  colon  is  a  repository,  and  should  not  be  indiscrimi- 
nately unloaded ;  one  of  its  functions  is  absorption  of  nutrition, 
and  another  is  secretion  of  mucus  that  lubricates  the  lining  so 
as  to  prevent  injury  and  facilitate  onward  movements  of  con- 
tents. The  action  of  water,  when  too  freely  used  in  the  colon, 
is  to  wash  away  the  mucus,  unloading  it  too  soon  and  causing 
colic.  However,  it  is  a  move  in  the  right  direction,  and  has 
done  much  good  and  little  harm. 

Many  cases  of  rectal  disease  can  be  cured  by  office  treat- 
ment, when  the  toilet  outlined  here  is  coupled  with  it.  Some 
gynecological  cases  baffle  the  doctor  by  fecal  accumulation, 
thus  keeping  up  congestions  in  the  parts  he  is  working  on, 
which  go  on  kindly  if  the  rectum  is  looked  after.  The  en- 
larged prostates  of  old  men,  and  of  others  not  so  old,  are  prob- 
ably caused  in  very  many  cases  by  this  unhygienic  condition 
of  the  rectum.  So  many  cases  called  by  the  laity  "water  trou- 
ble," "bladder  trouble,"  or  "kidney  trouble"  are  simply  cases 
of  this  prostatic  enlargement  due  to  rectal  irritation;  but  doc- 
tors prescribe  medicines,  and  the  patients  take  everything 
almost,  while  the  use  of  a  few  sounds,  rectal  plugs,  and  rectal- 
douching  after  stool  give  relief  at  once.  This  is  not  a  panacea 
for  all  the  ills  of  life,  but  it  gives  an  amount  of  comfort  more 
than  commensurate  with  the  time  and  trouble  employed  carry- 
ing out  the  procedure. 

I  do  not  know  of  any  other  theory  of  the  cause  of  so 
many  rectal  troubles  as  the  one  mentioned  here.  If  you  do  not 
think  there  is  comfort  in  this  toilet,  try  it  a  short  time  on 
yourself,  then  you  will  recommend  it  to  your  friends. 


250  ORIFIG1AL   SURGERY. 


CHAPTER  XXXIV. 


A  FEW  POINTS  ON  THE  ANATOMY  AND  PHYSIOLOGY 
OF  THE  RECTUM— POCKETS  AND  PAPILLAE. 


E.   H.   PRATT,   M.   D. 


It  is  not  our  purpose  to  rehash  in  the  present  connection 
the  contents  of  already  existing  text  books  upon  the  anatomy 
of  the  rectum ;  but  there  are  some  facts  and  fancies  about  the 
rectum  which  seem  to  have  been  either  overlooked  or  misun- 
drstood  in  previous  writings  upon  this  subject,  and  a  few  of 
these  we  may  profitably  discuss. 

We  shall  consider  the  rectum  from  an  orificial  standpoint 
and  therefore  confine  our  attention  exclusively  to  the  last  inch. 
At  its  upper  portion,  the  rectum,  which  is  a  continuation  down- 
ward of  the  sigmoid  flexure  of  the  colon,  has  four  coats — the 
serous,  muscular,  cellular  and  mucous.  But  this  lower  part 
has  three — the  serous  coat  being  dispensed  with,  its  entire 
structure  being  made  up  of  muscular,  cellular  and  mucous 
tissues. 

Immediately  above  the  last  inch  the  middle  portion  of  the 
rectum  is  a  bag  so  distended  as  to  constitute  the  most  ca- 
pacious expansion  of  the  intestinal  tract  below  the  stomach. 
The  last  inch  presents  a  sudden  narrowing  of  the  canal,  con- 
stituting its  most  constricted  portion.  It  is  directed  downward 
and  backward.  Its  upper  boundary  is  the  upper  edge  of  the 
internal  sphincter;  its  lower  boundary  is  the  very  margin  of 
the  anus,  gripped  by  the  lower  fibres  of  the  external  sphincter. 

Let  us  first  consider  a  few  points  of  the  anatomy  of  this 
part  and  a  little  later  on  mention  somewhat  of  its  physiology. 
In  order  to  present  what  we  have  to  say  on  this  subject  in  an 
orderly  manner  let  us  give  our  attention  briefly,  first,  to  the 
mucous  membrane,  next  to  the  areolar  tissues  and  lastly  to  its 
muscular  structure. 

First,  then,  what  of  the  mucous  membrane  lining  the  last 
inch  of  the  rectum?  Below  it  thickens  and  pales  into  the  in- 


ORIFICIAL   SURGERY.  251 

tegument  with  which  it  is  continuous.  Above  it  softens  and 
blushes  into  the  rosy  lining  of  the  middle  portion  of  the  rec- 
tum, so  that  the  natural  color  of  the  mucous  membrane  of  this 
part  presents  a  delicate  shading,  from  the  pale  color  of  the 
skin  observed  at  the  anus,  to  the  deeper  reddening  above. 

If  the  surface  of  the  perineum  be  examined,  it  presents 
a  very  delicate  raphe,  extending  in  the  female,  from  the  an- 
terior margin  of  the  anus  to  the  posterior  fourchette  of  the 
vagina.  In  the  male,  starting  as  in  the  female  at  the  anterior 
margin  of  the  anus,  and  then  extending  along  the  whole  ex- 
tent of  the  scrotum  and  continuing  along  the  lower  surface 
of  the  penis  as  far  as  the  margin  of  the  foreskin;  just  as 
though  a  man's  skin  were  a  closely  fitting  bag  into  which  he 
had  been  carefully  crowded  and  the  mouth  of  the  bag  subse- 
quently united  along  the  base  of  the  body. 

The  mucous  membrane  of  the  body  (for  there  is  but  one, 
as  all  mucous  surfaces  are  but  continuations  of  one  common 
tract)  is  merely  an  internal  skin  which  meets  the  external  skin 
at  its  inlets  and  outlets.  Its  inlets  are  in  and  about  the  face 
and  here  the  transition  from  skin  to  mucous  membrane  is  quite 
abrupt.  At  the  margin  of  the  lips,  at  the  edges  of  the  nos- 
trils, at  the  borders  of  the  eyelids,  skin  structure  seems  sud- 
denly to  change  into  the  more  delicate  organism  which  we 
call  mucous  membrane  and  the  line  of  union  in  each  case  is  so 
well  marked  and  apparent  as  to  be  readily  observed  by  the 
naked  eye.  At  the  lower  openings  of  the  body,  however,  the 
change  is  not  so  abrupt.  In  the  male,  the  lining  of  the  fore- 
skin which  is  called  mucous  membrane  is  quite  similar  in  tex- 
ture to  its  covering  which  is  called  skin  and  the  dividing  line 
between  the  two  is  not  finely  drawn. 

So,  too,  at  the  vulva.  The  skin  which  covers  the  labia  ma- 
jora  passes  so  gradually  into  the  mucous  membrane  which  pro- 
tects the  labia  minora  that  the  line  is  by  no  means  sharply 
drawn.  At  the  rectum  in  either  sex,  the  skin  instead  of  pass- 
ing so  abruptly  into  mucous  membrane  as  to  present  a  sharp 
dividing  line,  as  at  the  margin  of  the  lips,  continues  into  the 
rectum  for  some  distance  as  skin,  growing  more  and  more  deli- 
cate until  finally  at  a  point  corresponding  to  the  upper  bor- 


252  ORIFICIAL   SURGERY. 

der  of  the  internal  sphincter,  every  vestige  of  skin  structure 
which  is  still  left  suddenly  disappears  and  from  there  upwards 
the  lining  of  the  intestine  is  mucous  membrane  proper. 

Upon  careful  examination  of  the  rectum  with  a  bivalve 
speculum,  or  what  is  better,  by  means  of  T  forceps,  everting 
the  last  inch  of  the  rectum,  the  fine  line  which  unites  the  skin 
and  the  mucous  membrane  at  this  point  can  usually  be  ob- 
served by  the  naked  eye.  More  properly,  then,  the  last  inch 
of  the  rectum  is  lined  not  by  mucous  membrane  but  by  a  deli- 
cate formation  of  the  skin  which  approaches  the  structure  of 
the  mucous  membrane  at  its  upper  margin  and  which  becomes 
more  characteristically  skin  in  structure  at  the  anus. 

This  lining  of  the  last  inch  of  the  anus,  be  it  considered 
skin  or  mucous  membrane,  however,  is  smooth  in  texture  when 
well  distended  by  means  of  the  large  sized  bivalve  speculum 
and  in  a  healthy  state  presents  a  uniform  color,  gradually 
fading  as  mentioned  before,  from  the  ruddy  color  of  the  mu- 
cous membrane  to  the  pale  appearance  of  the  integument  at 
the  anus. 

Its  superficial  covering  is  squamous  epithelium,  its  deeper 
layers  of  the  columnar  variety.  The  squamous  form  of  epi- 
thelium stops  at  the  upper  border  of  the  internal  sphincter 
where  the  delicate  line  already  mentioned  marks  the  spot 
where  the  last  trace  of  skin  structure  fades  away;  and  above 
that  the  epithelial  lining  of  the  rectum  is  entirely  of  the  col- 
umnar variety,  thereby  constituting  the  membrane  of  which 
it  forms  a  covering,  a  genuine,  full-fledged  mucous  membrane. 

As  the  papillary  layer  of  the  skin  is  more  marked  than  the 
corresponding  layer  of  mucous  membrane,  so  the  lining  of  the 
last  inch  of  the  rectum  presents  a  much  more  perfect  papillary 
growth  than  is  found  in  the  mucous  membrane  above.  This 
means  that  it  is  more  highly  organized  and  thoroughly  sup- 
plied with  terminal  nerve  fibres  and  vascular  loops. 

Right  here  it  may  be  well  to  call  attention  to  a  subject 
upon  which  there  exists  at  the  present  time  a  great  difference 
of  opinion.  It  concerns  the  appearance  of  the  mucous  mem- 
brane at  this  very  point,  namely,  at  the  upper  margin  of  the 
internal  sphincter  where  the  last  vestige  of  skin  passes  away 


OEIFIC1AL   SURGERY.  253 

and  mucous  membrane  proper  begins;  where  this  boundary 
line  is  marked  by  a  very  delicate  raphe,  if  I  may  so  call  it; 
and  where  surgeons  and  anatomists  differ  as  to  the  normal 
appearance  of  the  part ;  and  where  the  debate  is  still  on  as  to 
whether  the  formations  called  pockets  and  papillae,  which  often 
appear  in  this  locality,  are  to  be  regarded  as  anatomical  or 
pathological. 

Let  me  make  a  few  quotations  previously  to  defining  my 
own  position  on  the  subject. 

The  following  short  paragraph  is  found  on  page  309  of 
Bell's  Anatomy  of  the  Human  Body,  published  in  1829: 

"The  internal  coat  of  the  rectum  does  not  deserve  the 
name  of  villous  nor  of  papillaris.  Its  surface  is  smooth,  and 
there  are  often  distinctly  seen  little  foramina  like  the  mouths 
of  ducts  or  follicles,  in  part  the  source  of  the  mucous  discharge, 
which  is  sometimes  poured  from  this  gut.  Towards  the  anus 
the  folds  become  longitudinal,  and  terminate  in  the  notched- 
like  irregularities  of  the  margin." 

On  page  380  of  the  edition  of  Cruveilhier's  Anatomy,  pub- 
lished in  1847,  occurs  the  following  descriptive  language  with 
reference  to  the  mucous  membrane  of  the  rectum: 

' '  The  skin  around  the  borders  of  this  orifice  which  is  con- 
stantly closed,  contains  a  great  number  of  sebaceous  follicles 
and  covered  with  hair  in  the  male,  it  passes  deeply  into  the 
orifice  to  become  continuous  with  the  mucous  membrane  and 
presents  a  great  number  of  radiated  folds  which  are  effaced 
during  dilatation.  The  point  at  which  it  becomes  continuous 
with  the  mucous  membrane  is  deserving  of  notice.  It  is  with- 
in the  rectum  at  a  distance  of  several  lines  from  the  anus  prop- 
erly so  called,  and  is  marked  by  a  waved  line  which  forms  a 
series  of  arches  or  festoons  having  their  concavities  directed 
upward.  Sometimes  there  are  small  pouches  in  the  situation 
of  these  arches  opening  upward. 

From  the  angles  at  which  the  arches  unite  more  mucous 
folds  proceed,  and  small  foreign  bodies  detached  from  the 
faeces,  are  often  retained  in  the  culs-de-sac,  and  become  the 
causes  of  fistulae." 


254  OEIFIGTAL   SURGERY. 

In  Morton's  Anatomy,  published  in  1849,  on  page  317,  he 
says:  "The  anus  is  about  an  inch  in  front  of  the  os  coccygis. 
Its  external  margin  is  of  a  darker  color  than  the  surrounding 
integument,  is  supplied  with  sebaceous  follicles  and  more  or 
less  covered  with  hair.  The  epidermis  becomes  very  dark 
over  this  surface  and  terminates  within  in  a  true  epithelium. 
The  point  at  which  the  skin  becomes  continuous  with  the  mu- 
cous membrane  is  deserving  of  notice.  It  is  within  the  rec- 
tum at  a  distance  of  some  lines  from  the  anus  properly  so 
called,  and  is  marked  by  a  waved  line,  which  forms  a  series 
of  arches  or  festoons  having  their  concavities  directed  upward. 
Sometimes  there  are  small  pouches  in  the  situation  of  these 
arches  opening  upward.  The  mucous  membrane  of  the  rectum 
is  remarkably  thick  and  vascular,  and  forms  a  column  below 
which  pursues  a  longitudinal  course,  and  being  crossed  by 
folds  of  the  same  membrane  towards  the  anus,  gives  rise  to  the 
pouches  just  mentioned." 

Morton  has  thus  quoted  Cruveilhier,  giving  him  proper 
credit,  thus  showing  that  he  merely  endorsed  the  sentiments 
of  his  predecessor  without  probably  any  personal  investiga- 
tion of  the  subject. 

On  page  50  in  Homer's  Anatomy  and  Histology,  published 
in  1846,  occurs  the  following: 

"The  mucous  coat  of  the  rectum  is  thick,  red  and  fungous, 
and  abounds  in  mucous  lacunae  and  glands.  It  is  smoothly  laid 
above,  but  below  it  is  thrown  into  superficial,  longitudinal 
folds  called  columns.  At  the  lower  ends  of  the  wrinkles,  be- 
tween the  columns,  are  small  pouches  of  from  two  to  four  lines 
in  depth,  the  orifices  of  which  point  upward;  they  are  occa- 
sionally the  seat  of  disease,  and  produce,  when  enlarged,  a 
painful  itching. 

An  original  observation  of  Dr.  Physick,  on  the  nature  of 
these  affections,  and  the  remedy  for  which  consists  in  slit- 
ting them  open  or  removing  them,  induced  me  to  look  for  the 
ordinary  natural  structure,  which  I  have  ascertained  to  be  as 
now  described." 

In  Vol.  II,  of  Essays  on  Practice  of  Medicine  and  Sur- 
gery, published  by  Lea  &  Blanchard  of  Philadelphia,  in  1841, 


ORIFICIAL    SURGERY. 


255 


is  an  article  by  Reynell  Coates,  M.  D.,  in  which  he  speaks  con- 
cerning pockets  in  the  following  manner: 

"Sacculi  of  the  Anus.  The  venerable  Emeritus,  Professor 
of  Anatomy  in  the  University  of  Pennsylvania,  had  been  in 
the  habit  of  noticing  in  his  former  annual  course  of  surgical 
lectures,  a  peculiar  condition  of  the  anus,  in  which  there  ex- 


A  vertical  section  of  the  anterior  parietes  of  the  anus,  with  the  whole  canal  dis- 
played so  as  to  show  the  relations  of  the  sacculi  of  the  middle  region,  and  their  rela- 
tions to  the  surrounding  parts,  their  orifices  being  marked  by  bristles. 

A.  A.  Columns  of  the  Rectum.  B,  B.  Rudiments  of  columns.  C.  Internal  Sphincter. 
P.  External  Sphincter  I.  Rudimentary  or  imperfect  Sacculi.  K.  K.  Radiated  folds 
of  the  skin,  terminating  on  the  surface  of  the  nates. 

n.  A  bristle  in  one  of  the  sacs. 

ists  certain  well-defined  pouches  or  sacs  within  the  canal,  which 
by  occasionally  arresting  small  portions  of  faces,  or  minute 
foreign  bodies,  give  rise  to  great  inconvenience,  and  demand 
the  performance  of  a  peculiar  operation  for  the  relief  of  the 
patient.  (See  Art.  III.)  Dr.  Horner,  in  prosecuting  some  ex- 
aminations, post-mortem,  with  the  view  of  elucidating  this 


256  ORIFIG1AL   SURGERY. 

subject,  was  surprised  to  find  a  series  of  semilunar  valvules 
within  the  canal,  such  as  have  been  hinted  at,  by  certain 
anatomists,  as  an  occasional  occurrence,  but  the  existence  of 
which  has  been  repeatedly  denied  by  others.  His  attention 
being  once  fairly  called  to  this  structure,  Dr.  Horner  discov- 
ered these  valvules  in  every  body  which  he  examined  for  the 
purpose,  and  therefore  draws  the  legitimate  conclusion  that 
they  are  normal  and  constant.  The  following  description  is 
drawn  from  the  appearances  presented  by  four  different  prep- 
arations, taken  promiscuously  from  a  considerable  number 
which  the  Professor  did  us  the  favor  to  submit  to  examination, 
and  the  accompanying  figure  has  been  executed  from  one  of 
them. 

Immediately  below  the  margin  of  the  internal  sphincter 
we  find  a  series  of  membranous  pockets  or  sacculi,  correspond- 
ing in  number  with  the  grooves  between  the  columns  of  the 
rectum,  one  of  which  grooves  is  directed  towards,  and  termi- 
nates in,  each  of  the  culs-de-sac.  On  the  outer  side  the  sacculi 
are  lined  by  the  mucous  membrane  of  the  grooves,  prolonged 
into  the  intervals  of  the  hemispherical  eminences  already  no- 
ticed, but  which  are  not  sufficiently  distinct,  after  death,  to 
be  well  represented  in  a  drawing  from  nature. 

Internally,  or  on  the  side  next  the  canal,  the  saculli  are 
completed  by  portions  of  loose  membrane,  which  are  processes 
from  the  reverted  integuments  lining  the  canal  below.  Each 
of  these  loose  portions  is  attached  at  either  end  to  the  base  of 
one  of  the  columns  of  the  rectum,  and  its  free  margin  hangs 
in  a  curve  between  these  points,  thus  forming  a  purse  with 
the  mouth  presenting  upwards,  and  resembling,  in  some  degree, 
one  of  those  formed  between  the  valves  of  the  aorta  and  the 
parietes  of  that  vessel.  Unlike  the  sacculi  said  to  be  sometimes 
formed  by  the  intersection  of  the  transverse  and  longitudinal 
folds  of  the  rectum  near  the  upper  part  of  the  anal  canal, 
these  pockets  may  be  compressed,  but  cannot  be  obliterated 
by  the  distention  of  the  anus.  Their  number,  form  and  po- 
sition must  necessarily  vary,  with  those  of  the  columns  and 
swellings,  which  give  them  attachment;  and,  like  the  columns, 
some  of  them  are  frequently  rudimentary.  The  upper  mar- 


ORIFIG1AL   SURGERY.  257 

gins  of  these  pockets,  taken  collectively,  appear  to  form  the 
festoon  mentioned  by  Cruveilhier  as  the  termination  of  the 
cuticle. 

The  importance  of  the  relations  between  these  pockets  and 
the  phenomena  of  fissure,  stricture,  etc.  are  subjects  for  fu- 
ture examination.  As  to  their  physiological  uses,  this  is  not 
the  proper  place  to  discuss  all  the  ideas  which  they  suggest; 
suffice  it  to  say,  that  numerous  mucous  follicles  appear  to  dis- 
charge themselves  into  their  cavities,  and  that  the  passage  of 
faeces  must  compress  them  and  expel  their  contents,  thus  aid- 
ing in  the  lubrication  of  that  part  of  the  anal  canal  which  is 
invested  with  cuticle,  and  therefore  less  capable  of  protecting 
itself,  particularly  at  the  moment  when  this  lubrication  is  most 
necessary.  The  occasional  existence  of  such  sacs,  or,  as  they 
have  been  termed,  lacunas,  or  valves  in  the  anus,  has  been  no- 
ticed by  several  writers:  M.  Ribes,  one  of  the  most  laborious 
investigators  of  the  pathology  of  the  rectum,  refers  to  Glis- 
son,  Ruysch  and  Morgagni,  as  among  the  number.  This  gen- 
tleman, in  an  essay  written  some  years  ago,  stated  that  he  had 
been  totally  unable  to  detect  them  in  the  course  of  his  dis- 
sections, though  pursued  for  twenty-five  years.  He  mentions, 
indeed,  three  or  four  depressions  apparently  lined  with  exter- 
nal integument,  and  perfectly  smooth,  placed  in  the  anus,  four 
or  five  lines  above  the  margin,  resembling  the  dilatations  of 
the  aorta  and  pulmonary  arteries  after  the  removal  of  the  sig- 
moid  valves,  but  he  could  not  detect  any  opening  or  loose  mem- 
brane about  them.  It  seems  probable,  then,  that  he  was  de- 
ceived by  the  collapse  or  obliteration  of  the  cavities,  which  pre- 
vented his  observing  the  free  margins  of  the  valves,  as  they 
have  been  improperly  called ;  this  is  the  more  probable,  as  his 
attention  was  particularly  directed  to  the  condition  of  the 
parts  when  in  a  diseased  state,  from  the  existence  of  fistula  in 
ano.  (Recherches  sur  la  situation  de  1'orifice  interne  de  la 
fistule  a  1'anus.  Rev.  Medicale,  1820.)  In  a  more  recent  es- 
say on  the  same  subject,  M.  Ribes  describes  these  pockets  with 
considerable  accuracy,  stating  that  he  has  found  in  one  sub- 
ject, four,  and  in  others,  three  depressions,  protected  by  their 
loose,  semilunar,  velvet-like  covering,  and  that  in  the  inter- 


258  ORIFIGTAL   SUBGEBY. 

vals  between  these,  others  less  developed  were  noticed.  (Mem- 
oires  de  la  Societe  d 'Emulation,  IX,  107.)  Nowhere,  however, 
are  the  precise  position  and  connections  of  these  parts  de- 
scribed with  accuracy,  though  the  author  just  quoted  remarks 
that  they  are  externally  in  contact  with  the  hemorrhoidal 
plexus,  and  that  the  slightest  wound  or  ulcer  on  their  inner 
surface  must  endanger  the  occurrence  of  fistula. 

Many  authors  have  described  the  appearance  of  culs-de- 
sac  somewhat  similar  to  these  pouches,  formed  by  transverse 
dupllcatures  of  the  mucous  tissue  just  above  the  anus  or  in  the 
upper  portion  of  its  canal,  passing  from  one  column  of  the 
rectum  to  another.  No  doubt  they  may  occasionally  exist,  but 
M.  Ribes  declares  that  he  has  never  been  able  to  detect  them. 

The  numerous  partial  partitions  of  the  rectum,  sometimes 
formed  by  the  mucous  membrane  still  higher  up  in  the  canal, 
are  altogether  beyond  the  range  of  the  present  article,  and 
cannot  be  confounded  with  these  more  constant  and  regular 
valvules." 

Again  on  page  123: 

' '  Preternatural  Pouches  or  Cavities  of  the  Anus.  This  is  a 
peculiar  form  of  disease  of  the  anus,  rare,  indeed,  but  much 
less  so  than  some  that  have  been  already  described,  although 
it  appears  to  have  escaped  the  notice  of  surgical  writers. 
Though  agreeing  in  location  and  perhaps  arising  from  similar 
causes  with  some  forms  of  occult  fistula  and  abscess  of  this 
region,  it  differs  from  them  essentially  in  its  progress,  symp- 
toms and  requisite  treatment.  It  was  first  made  known  to 
the  profession  by  Dr.  Physick,  under  whose  care  a  case  oc- 
curred very  soon  after  his  first  settlement  as  a  practitioner  in 
Philadelphia  in  1792,  and  it  was  regularly  described  by  him  in 
his  annual  course  of  surgical  lectures.  Most  of  the  patients 
who  have  been  brought  to  Dr.  Physick  for  advice  in  consulta- 
tion by  other  practitioners,  have  been  thought  to  labor  under 
an  imaginary  complaint  or  under  neuralgia  of  the  anus;  and 
there  is  no  reason  to  suspect  that  some  of  the  cases  described 
as  neuralgic,  by  various  authors,  have  been  really  instances 
of  the  disease  of  which  we  are  now  speaking. 


ORIFK1AL   SURGERY.  259 

The  symptoms  which  mark  the  presence  of  these  preter- 
natural cavities  are  as  follows:  The  patient  sometimes  makes 
little  or  perhaps  no  complaint  during  the  intervals  between 
the  stools,  etc.,  etc. 

In  operating,  it  is  necessary  to  remove  the  greater  part  of 
the  internal  covering  of  the  cavity,  together  with  the  orifice, 
in  order  to  insure  a  cure ;  for  if  any  portion  is  allowed  to  re- 
main beneath  the  orifice,  the  same  sluggishness  of  tissue  may 
continue  in  this  remaining  part,  and  after  the  wound  pro- 
duced by  the  operation  has  healed,  a  cavity  of  smaller  dimen- 
sions may  still  subsist,  and  give  rise  to  a  return  of  symptoms. 
After  the  excision  of  the  inner  parietes,  no  disposition  to  re- 
traction in  consequence  of  the  loss  of  substance  is  evidenced 
by  the  cicatrix,  or  at  least,  no  such  disposition  has  been  yet 
observed  in  any  case  not  complicated  with  other  diseases;  a 
circumstance  that  proves  the  wide  difference  between  the  con- 
dition of  this  cavity  and  that  of  a  suppurating  or  granulating 
surface. 

The  mode  of  operating  devised  by  Dr.  Physick  for  the  re- 
lief of  this  complaint,  (one  which  has  proved  successful  in 
every  instance,)  consists  in  drawing  down  the  membranous 
covering  of  the  cavity  by  means  of  a  bent  probe,  and  then  re- 
moving the  whole  of  this  portion,  or  as  much  of  it  as  possible, 
by  the  scissors,  taking  care  to  include  the  orifice  by  which 
the  probe  enters,  in  the  part  excised.  The  opposite  surface  is 
thus  laid  completely  open  to  the  anal  canal.  It  must  be  borne 
in  mind  that  several  of  these  cavities  may  exist  at  the  same 
time,  and  that  after  the  patient  is  relieved  by  the  cure  of  these, 
others  may  be  formed  consecutively,  in  some  instances.  In 
one  case  particularly,  numerous  operations  were  successively 
performed  during  a  period  of  several  months  for  the  extirpa- 
tion of  a  series  of  these  sacs  which  were  developed  one  after  an- 
other, on  the  same  side  of  the  canal,  in  the  same  individual. 
The  surgeon  should  therefore  repeat  the  operation  as  often  as 
necessary,  until  the  complaint  is  effectually  eradicated ;  and  it 
is  evident  that  due  attention  to  the  habitual  condition  of  the 
bowels,  so  strongly  insisted  on  in  the  preceding  sections,  is 


260  ORIFIG1AL   SUEGEBY. 

equally  imperative  here,  if  we  would  completely  remove  the 
causes  of  the  disease. 

We  cannot  quit  the  present  subject  without  expressing 
the  pleasure  we  enjoy  on  this,  as  on  all  other  occasions,  in  se- 
curing to  the  rightful  claimant  of  services  rendered  to  hu- 
manity; yet  it  is  mournful  to  reflect  that  the  vast  funds  of 
knowledge  and  experience  accumulated  by  one  who  has  filled, 
so  long  and  so  honorably,  the  first  station  among  American 
surgeons,  should  remain  accessible  to  but  a  small  portion  of 
the  medical  public.  They  lie  chiefly  buried  in  his  own  mind, 
or  in  the  memory  of  those  who  have  enjoyed  the  happiness  of 
attending  his  deeply  impressive  discourses.  Abroad,  a  great 
surgeon  whose  avocations  prevent  him  from  publishing  the 
results  of  his  experience,  has  always  his  reporters.  The  novel 
opinions  of  Sir  A.  Cooper,  of  Depuytren,  etc.,  reach  us  almost 
as  soon  as  uttered,  through  the  medium  of  the  press;  but  on 
this  side  of  the  Atlantic,  we  have  been  shamefully  negligent  of 
our  own  claims  to  distinction.  That  no  one  who  has  enjoyed 
the  privilege  of  hearing  the  clinical  remarks  and  the  public 
lectures  of  Dr.  Physick,  has  stepped  forward  to  do  justice  to 
the  Professor  and  the  Profession,  is  not  only  a  matter  of  sur- 
prise, but  a  just  cause  of  national  regret.  How  small  a  por- 
tion will  be  ultimately  rendered  to  Ca?sar,  of  all  that  bears  his 
image  and  superscription." 

These  preternatural  pouches  of  cavities  of  the  anus,  as 
they  have  been  called  by  Dr.  Physick,  were  undoubtedly 
elongated  and  ulcerated  pockets.  Had  Dr.  Physick  possessed 
a  good  rectal  bivalve  with  which  to  examine  the  rectum,  or 
even  T  forceps  with  which  to  evert  it,  and  been  aware  of  the 
fact  that  the  rectum  could  possess  mischievous  pathology  with- 
out presenting  local  symptoms,  he  would  have  given  the  world 
a  better  lesson  in  Orificial  Surgery  and  they  would  not  have 
forgotten  it  so  soon. 

Nevertheless,  the  able  surgeon  deserves  great  credit  for 
what  he  accomplished  with  merely  a  bent  probe,  without 
speculum  or  without  knowledge  of  the  influence  of  rectal  con- 
ditions over  the  capillary  circulation  and  deserves  the  full 
credit  for  the  first  discovery  of  rectal  pockets. 


ORIFIC1AL   SURGERY.  261 

Horner  was  not  very  generous  or  fair  as  will  appear  from 
the  preceding  quotation  in  permitting  these  cavities  to  be 
called  sacculi  Horneri  when  his  own  investigations  were  made 
as  a  result  of  the  previous  investigations  and  discoveries  of  Dr. 
Physick.  In  fact,  these  historical  clippings  suggest  a  slight 
degree  of  professional  difference  of  opinion.  Dr.  Physick 
would  fish  for  pockets  blindly  with  a  blunt  hook  and  cut  out 
all  he  could  find,  undoubtedly  puncturing  the  bottom  of  them 
in  his  crude  way  of  examining,  so  they  appeared  longer  than 
they  really  were ;  while  Dr.  Horner,  because  he  found  them  in 
a  few  dead  bodies,  regarded  them  as  purely  anatomical  forma- 
tions and  chronicled  them  as  such.  Had  he  known  that  shal- 
low pockets  even  when  not  ulcerated  were  a  source  of  mis- 
chief and  could  cause  reflex  disturbance  in  any  part  of  the 
body,  and  that  they  were  a  positive  failure  for  anatomical  pur- 
poses, he  would  have  given  them  a  more  careful  consideration 
than  he  has  done  in  this  misleading  paragraph.  As  it  was, 
however,  he  did  the  best  he  could  and  told  all  he  knew  about 
them  and  a  little  more ;  his  observations  and  opinions  are  not 
extensive,  as  118  words  hold  them  both  comfortably. 

With  our  present  knowledge  of  rectal  pockets,  which  is 
much  greater  than  was  possessed  by  these  gentlemen,  it  is  in- 
teresting to  scan  these  pages  of  medical  history. 

On  page  660,  Vol.  II.,  Gross'  Surgery,  published  in  1862, 
the  writer  says:  "The  singular  affection  of  the  anus,  first  de- 
scribed by  Dr.  Physick,  under  the  name  of  the  encysted  rec- 
tum, is  occasionally  met  with,  though  comparatively  seldom.  A 
more  appropriate  appellation  for  it  would  be  sacciform  disease 
of  the  anus,  as  it  consists  simply  in  an  altered  condition  of  the 
sacs,  pockets  or  pouches  naturally  existing  in  this  situation, 
to  the  number,  in  many  cases,  of  eight,  ten,  or  even  a  dozen,  as 
seen  in  Fig.  414,  from  a  specimen  in  my  cabinet.  These  sacs 
are  always  very  small  in  early  life,  but  as  their  development  is 
regularly  progressive  they  are  capable  of  acquiring  a  consid- 
erable size,  especially  if,  as  not  unfrequently  happens,  they 
form  a  receptacle  of  hardened  fosces,  inspissated  mucus,  or 
small  extraneous  bodies.  From  these  and  other  causes,  not 
always  very  obvious,  they  become  the  seat  of  morbid  action, 


262  ORIFICIAL   SURGERY. 

as  inflammation,  suppuration  and  ulceration,  often  attended 
with  exquisite  torture.  A  number  of  pouches  may  be  thus  af- 
fected simultaneously,  or  one  after  another  may  become  in- 
volved, until  nearly  the  whole  of  the  anus  may  suffer.  The  size 
of  the  individual  pockets  varies  from  that  of  a  small  depres- 
sion, hardly  capable  of  holding  a  split  pea,  up  to  that  of  a 
cavity  large  enough  to  admit  the  point  of  the  little  finger.  The 
disorder  occurs  only,  or  principally,  in  old  subjects,  whose 
lower  bowel  is  habitually  distended  with  fo3eal  matter,  and 
who  suffer  much  from  the  congestion  of  the  ano-rectal  tissues. 


POUCHES  OP  THE  RECTUM. — Gross'  Surgery 

Sacciform  enlargement  of  the  anus  is  generally  tardy  in 
its  progress  and  insidious  in  its  character,  its  existence  being 
frequently  not  suspected  for  years.  For  a  long  time  the  pa- 
tient is  merely  conscious  of  uneasy  sensations  in  the  parts; 
vague  as  to  their  nature  and  uncertain  as  to  their  recurrence. 
Frequently  one  of  the  earliest  symptoms  complained  of  is  a 
feeling  of  pressure  or  weight  just  within  the  anus,  or  a  dis- 
tressing itching  similar  to  what  is  produced  by  the  presence 
of  ascarides. 

As  the  disorder  proceeds,  but  generally  not  until  it  has 
made  considerable  progress,  the  patient  begins  to  experience 
pain,  especially  immediately  after  defecation,  lasting  often 
several  bourse  after  the  act  has  been  completed ;  it  is  commonly 
of  an  aching,  burning,  or  smarting  character,  and  is  seldom 
confined  to  parts  more  immediately  implicated,  but  is  apt  also 
to  extend  to  the  buttocks,  perineum,  back  and  thighs.  It  is 
not,  however,  after  every  evacuation  that  there  is  severe  pain; 


ORIFIG1AL   SURGERY. 


263 


cases  occurring  in  which  it  is  entirely  absent  or  nearly  so,  for 
days  together,  depending  probably  upon  the  fact  that  the  af- 
fected pouches  are  sometimes  completely  emptied  of  their  con- 


tents, and,  of  course,  relieved  from  pressure.  An  increased  se- 
cretion of  mucus  is  usually  observed,  but  it  is  rare,  except 
when  the  sacs  are  inflamed  or  ulcerated,  to  see  any  discharge 
of  pus. 


264  ORDFIG1AL  SURGERY. 

No  spasm  of  the  sphincter  muscles  accompanies  this  af- 
fection, as  is  the  case  in  fissure  of  the  anus.  To  ascertain  the 
real  nature  of  the  disease,  careful  exploration  is  necessary,  the 
instrument  used  for  the  purpose  being  a  common  pocket  probe, 
the  end  of  which  is  bent  into  a  hook,  and  passed  up  and  down 
the  anus  from  one  part  of  its  circumference  to  the  other.  As 
it  is  drawn  along  it  becomes  entangled  in  the  valve-like  folds 
of  the  sac,  the  seat,  size  and  sensibility  of  which  are  thus 
fully  revealed,  and  which  is  generally  so  transparent  as  to.  al- 
low the  probe  to  be  perceived  through  it.  The  examination  is 
always  painful,  and  it  may,  therefore,  be  made  while  the  pa- 
tient is  under  the  influence  of  chloroform.  The  proper  remedy 
for  this  complaint  is  excision  of  the  valve-like  fold  of  the  af- 
fected sac. 

To  do  this  all  that  is  required  is  to  draw  it  down  with  a 
tenaculum  or  seize  it  with  the  forceps  and  snip  it  off.  If  the 
bottom  of  the  pouch  is  in  an  ulcerated  condition  it  would  be 
well  at  the  same  time  to  scarify  its  surface,  in  the  hope  of  plac- 
ing it  thereby  in  a  more  favorable  condition  for  speedy  repara- 
tion. If  several  sacs  are  involved  they  should  all  be  operated 
upon  at  one  sitting." 

The  cut  in  Gross'  Surgery,  which  has  been  reproduced 
here  together  with  the  quotation,  presents  the  author's  idea 
of  the  natural  appearance  and  location  of  these  so-called  ana- 
tomical structures. 

The  preceding  cut,  taken  from  the  British  Medical  Journal, 
gives  one  the  same  impression  concerning  rectal  pockets,  sacs, 
or  pouches,  as  they  have  been  variously  called.  These  little 
structures  have  been  noticed  in  a  few  additional  places  in 
medical  literature,  but  as  the  remarks  about  them  are  similar 
to  those  already  given  it  is  needless  to  multiply  quotations. 

Dr.  Physick  seems  to  be  not  only  the  discoverer  of  the 
condition,  but  also  the  only  original  thinker  who  has  given 
them  his  attention.  It  is  too  bad  that  he  was  not  a  writer  as 
well  as  a  worker.  He  was  evidently  a  great  man  whose  works 
have  been  unchronieled. 

The  cures  which  he  made  by  excising  rectal  pockets  in  this 
way,  made  such  a  profound  impression  upon  his  time,  that  the 


ORIFIG1AL   SURGERY.  265 

tradition  of  them  still  lingers  in  the  minds  of  some  of  the  older 
practitioners  of  our  time.  There  has  also  come  down  to  us  a 
murmur  of  the  disrespect  and  senseless  storm  of  ridicule  and 
opposition  to  which  he  was  treated  by  his  professional  breth- 
ren for  the  great  and  original  work  which  should  have  re- 
ceived their  praise  instead  of  their  blame. 

If  he  wrote  upon  the  subject,  his  writings  have  been  ma- 
liciously expunged  from  medical  literature.  Had  he  realized 
when  he  cured  people  by  excising  rectal  pockets,  that  he  was 
standing  by  the  great  ocean  of  orificial  truth,  from  whose 
shores  he  was  simply  picking  a  pebble,  his  tongue  would  cer- 
tainly have  been  loosened,  his  pen  sharpened  and  the  imprint 
of  his  work  upon  the  medical  profession  would  have  been  more 
indelibly  made. 

Let  us  honor  him  for  his  originality,  for  possessing  the 
courage  of  his  convictions,  regretting  only  that  he  did  not 
leave  to  posterity  a  larger  inheritance. 

It  seems  as  though  orificial  surgery  should  have  been  born 
at  this  time.  In  all  the  quotations  which  we  have  made  and  in 
others  which  we  might  make,  they  are  described,  not  as  con- 
stant conditions,  but  as  frequently  occurring,  and  yet  they 
are  incongruously  dubbed  anatomy. 

But  concerning  the  anatomical  quotations  we  have  just 
made,  it  seems  to  me  some  effort  should  be  made  to  correct  the 
erroneous  impression  which  these  writings  have  made  upon 
the  profession  and  which  they  are  still  making  upon  the  minds 
of  those  who  rely  for  their  knowledge  upon  so  called  authority 
rather  than  upon  their  own  investigations. 

It  is  a  common  thing  in  any  department  of  history  for  mis- 
takes to  remain  uncorrected  so  long  or  so  imperfectly,  as  to  be 
recognized  as  facts  by  the  succeeding  generations.  We  still 
speak  of  the  rising  sun,  although  everybody  knows  that  the 
sun  does  not  rise.  We  still  call  our  native  land,  America,  al- 
though were  justice  done,  it  would  be  known  as  Columbia.  The 
arteries  were  so  named  because  they  were  supposed  to  contain 
air.  They  still  retain  their  name  although  we  are  better  in- 
formed as  to  their  contents.  In  the  same  way  rectal  pockets 


266  ORIFIGTAL   SURGERY. 

have  so  long  been  described  as  anatomical  formations  that  it 
will  be  a  Herculean  task  to  erase  the  name  from  anatomies  and 
transfer  it  to  works  on  pathology. 

There  is  one  point  which  favors  the  possibility  of  this 
achievement  and  that  is  that  they  have  not  been  recognized 
very  generally  even  by  anatomists.  Gray  and  most  other 
anatomists  do  not  even  mention  them.  Their  existence  has 
not  been  taught  in  medical  colleges  and  the  great  body  of 
medical  men  today  are  not  aware  that  there  is  such  a  thing  in 
existence  as  a  rectal  pocket  or  sac. 

There  is  a  good  deal  of  writing  upon  this  subject  at  the 
present  time,  but  I  am  sorry  to  say  that  the  majority  of  writ- 
ers, instead  of  exercising  an  independent  judgment,  have  sim- 
ply looked  up  the  musty  records  on  the  subject  and  are  doing 
what  they  can  to  reproduce  the  original  erroneous  notion  con- 
cerning them.  They  are  trying  to  prove  that  pockets  are  an- 
atomy and  are  unwilling  to  recognize  them  as  pathology. 

I  would  suggest  to  these  gentlemen  that  they  do  a  little 
more  independent  investigating  before  they  add  their  influ- 
ence to  any  further  extent  to  such  a  serious  professional  er- 
ror. Rectal  pockets  are  not  anatomy,  they  are  pathology.  The 
impressions  which  will  be  made  by  the  previous  cuts  in  this 
article  are  erroneous  in  the  extreme.  A  rectum  presenting  the 
appearance  as  illustrated  in  these  cuts  will  not  be  found  once  in 
a  hundred  cases.  And  when  it  does  exist,  it  is  a  very  sick 
rectum,  indeed,  and  wholly  unfit  to  pose  as  an  ideal  anatomical 
one.  The  cuts  give  a  very  correct  idea  of  the  location  of  pock- 
ets when  they  exist,  but  they  give  a  very  erroneous  idea  as 
to  the  frequency  and  symmetry  of  their  existence. 

It  is  easy  to  understand  why  this  great  mistake  has  been 
made  and  why  it  has  remained  so  long  unconnected:  In  the 
first  place,  anatomies  are  compiled  from  observations  upon  the 
dead;  and  orificialists  will  find  no  difficulty  in  comprehending 
why  these  formations  should  be  found  frequently  in  dead 
bodies.  In  the  next  place,  the  importance  of  the  rectum  has 
never  been  and  is  not  now  fully  appreciated  and  consequently 
has  been  neglected.  True,  hemorrhoids,  fistulas  and  fissures 
and  also  cancer  of  the  rectum  have  been  subjects  for  pro- 


ORinClAL   SUEGERY.  267 

f essional  attention  all  along  the  history  of  medicine ;  but  what 
the  preceding  race  of  doctors  did  not  know  about  the  rectum 
would  fill  volumes. 

They  did  not  know  that  dilatation  of  the  rectum  would 
affect  the  respiration,  that  it  would  flush  the  capillaries,  that 
it  would  resuscitate  the  drowned,  arouse  the  narcotized,  sober 
the  drunken,  awaken  the  anaesthetized,  etc.,  etc. ;  that  its 
pathology  exerted  any  special  influence  as  a  predisposing . 
cause  in  chronic  diseases. 

I  think  one  would  have  to  search  the  medical  literature 
through  endless  pages  before  he  would  find  an  article  on 
atrophy  of  rectal  tissues.  Even  satisfactory  rectal  specula  have 
never  been  in  existence,  so  far  as  we  can  find  out,  until  the 
present  time.  Search  London,  Paris,  Vienna,  Berlin  and  other 
European  centers  of  medical  education  for  a  satisfactory  in- 
strument with  which  to  explore  the  rectum  even  now,  and 
your  disappointment  will  perhaps  convince  you  that  the  in- 
struments heretofore  employed  for  examining  the  rectum  have 
been  wholly  inadequate  for  the  purpose,  and  you  will  be  bet- 
ter prepared  to  believe  that  medical  literature  is  both  imper- 
fect and  incomplete  in  its  dealings  with  rectal  pockets. 

Europeans  have  much  to  learn  from  Americans  upon  the 
subject  of  the  rectum  and  yet  the  great  body  of  American 
practitioners  are  wholly  unfamiliar  with  the  proper  appearance 
of  a  normal  rectum,  not  to  mention  the  pathological  one. 

Several  years  ago,  at  the  meeting  of  the  Illinois  Homoe- 
opathic State  Association,  held  in  Peoria,  I  presented  a  report 
upon  the  subject  of  pockets  and  papillae  in  which  the  following 
language  occurred: 

"They  are  as  common  as  piles;  more  prolific  of  mischief 
than  you  would  believe  without  a  special  acquaintance  with 
them,  and  still  they  have  been  hitherto  almost  unknown  to 
fame  and  very  much  neglected. 

"Our  current  literature  contains  little  or  no  mention  of 
them,  and  only  in  a  few  isolated  places  in  medical  lore  will 
you  find  any  indication  that  they  have  ever  been  discovered; 
and  nowhere,  so  far  as  I  am  aware,  are  they  well  described  or 
properly  noticed.  This  paper,  therefore,  is  but  an  act  of  jus- 


268 


OBIFIG1AL   SURGERY. 


PEN    SKETCHES  OP   POCKETS    AND    PAPILLAE   BY    DR.   NILS    BERGMAN,    LINCOLN 
PARK  SANITARIUM,  CHICAGO. 


Normal  rectum,  smooth,    dilatable,  presenting 
neither  pockets  nor  papillae. 


Single  club-sliaped  papilla. 


Two  broad-mouthed   pockets,  one  shallow  and 
one  deep. 


3 


Rectum  presenting  papillae,    sharp-pointed 
variety. 


Single  club-shaped  and  bifurcated  papilla. 


Three  stages  In  pocket  development  frequently 
seen  side  by  side,  ranging  from  a  mere  depression 
to  deep  form. 


ORIFICIAL  -SURGERY. 


26$ 


tice  to  a  condition  which  should  have  received  earlier  atten- 
tion, and  although  in  itself  but  a  feeble  effort,  it  is  to  be 
hoped  that  it  will  inaugurate  a  line  of  thought  and  investiga- 
tion that  will  in  time  place  the  complaint  where  it  belongs — 
in  the  regular  index  of  all  standard  surgical  works." 


\ 

Double  papillae  with  pocket  between,  common, 
ll! 


\ 

Marrow  pockets,  one  .shallow  and  one  deep. 


Papilla  with  pocket  behinu  i; 


The  white  transverse  line  in  these  cuts  illustrates  the  line  of  union  between  skin  and 
mucous  membrane,  and  is  located  at  upper  border  of  internal  sphincter. 

Before  writing  that  paper  I  had  carefully  investigated 
the  subject  and  was  perfectly  satisfied  in  my  own  mind  as  to 
the  nature  of  rectal  pockets.  I  had  settled  to  my  own  satis- 
faction the  question  as  to  whether  they  were  anatomy  or  path- 
ology ;  as  to  whether  an  individual  was  better  off  with  them  or 
without  them;  as  to  whether  they  had  better  be  let  alone  or 
completely  exterminated. 

The  position  which  I  took  at  that  time  was  a  radical  one, 
pronouncing  them  pathological  appearances  and  advising  their 
removal  under  all  circumstances.  Since  the  presentation  of  that 
paper  I  have  had  these  conditions  under  constant  observation 


270  ORIFIC'iAL    SURGERY. 

and  treatment.  I  have  examined  several  thousands  of  rec- 
tums  and  feel  amply  qualified  to  express  a  reliable  opinion  as 
to  the  nature  of  pockets,  and  to  offer  advice  concerning  them, 
that  I  feel  confident  will  bear  well  the  test  of  time. 

It  does  not  seem  to  me  in  the  least  degree  either  audacious 
or  hazardous  to  differ  in  opinion  upon  this  subject  with  those 
who  possessed  no  means  of  properly  examining  the  rectum, 
who  under-estimated  the  importance  of  rectal  pathology  and 
who  consequently  have  bestowed  very  little  attention  and 
thought  upon  the  subject ;  especially  as  my  surgical  experience 
in  this  matter  has  been  preceded  by  ten  years  practical  teach- 
ing of  anatomy  in  a  medical  college. 

The  mere  fact  that  a  man  has  written  a  book  and  died 
years  ago,  does  not  constitute  him  a  reliable  authority  upon 
any  subject.  In  the  long  ago,  the  world  was  not  so  old  as  it 
is  now,  and  for  one,  I  completely  disown  and  cast  aside  the 
chains  of  tradition,  that  make  superstitious  and  timid  souls 
mere  slaves  to  an  embryonic  past. 

The  human  body  is  built  upon  the  same  plan  today  that 
it  was  a  few  centuries  ago,  and  observation  is  as  valuable  now 
as  formerly,  and  knowledge  upon  almost  every  subject  has  ac- 
cumulated and  should  be  permitted  to  modify  opinions  that 
are  obviously  erroneous,  in  spite  of  the  fact  that  those  who 
expressed  them  have  gone  so  far  away  that  they  cannot  re- 
vise the  future  editions  of  their  own  works. 

Permit  me  to  mention  a  few  facts  in  this  connection  con- 
cerning rectal  pockets. 

Fact  No.  1.  Rectal  pockets  are  by  no  means  a  constant 
condition.  It  is  very  common  to  encounter  rectums  wholly 
devoid  of  the  formations. 

Fact  No.  2.  It  is  exceedingly  common  to  find  rectums 
possessed  of  merely  one  pocket ;  to  find  others  possessed  of  two 
pockets ;  to  find  yet  others  possessed  of  three  or  four  pockets. 

Fact  No.  3.  It  is  quite  uncommon  to  find  rectums  pos- 
sessed of  more  than  from  five  to  eight  pockets. 

Fact  No.  4.  Occasionally  an  operator  will  encounter  a 
rectum  which  possesses  from  ten  to  fifteen.  The  greatest  num- 


ORIFIC1AL   SURGERY.  271 

ber  of  pockets  which  I  have  seen  in  any  rectum  has  been 
seventeen. 

Fact  No.  5.  It  is  not  uncommon  to  find,  in  the  same  pa- 
tient, pockets  in  different  stages  of  development,  situated  side 
by  side;  one  of  which  will  present  merely  a  red  spot  above 
this  dividing  line  between  the  skin  and  mucous  membrane,  lo- 
cated at  the  upper  border  of  the  internal  sphincter  as  already 
described.  Close  to  it  will  be  another  red  spot  which  will  en- 
gage the  point  of  the  blunt  hook  for  perhaps  a  thirty-second 
or  sixty-fourth  of  an  inch.  Adjoining  this  will  be  a  third  into 
which  the  blunt  hook  will  pass  for  perhaps  an  eighth  of  an 
inch. 


SHABP  ft  SMITH  CHIM60 

Fact  No.  6.  When  the  patient  possesses  but  a  few  rectal 
pockets,  the  location  of  them  is  by  no  means  constant.  In  one 
case  it  will  be  a  single  pocket  under  the  prostate ;  in  another  it 
will  be  a  single  pocket  011  the  side  toward  the  coccyx.  Still 
another  case  will  have  but  two,  located  laterally. 

Fact  No.  7.  The  pockets  vary  much  in  depth  and  also  in 
width,  sometimes  being  so  shallow  and  narrow  as  to  require 
the  point  of  a  dull  tenaculum  to  engage  them,  and  this  for 
only  a  very  short  distance.  At  other  times  the  inverted  tube 
will  be  so  long  that  the  blunt  hook,  a  cut  of  which  is  pre- 
sented, is  not  of  sufficient  length  to  sound  its  depths.  At  other 
times  the  pocket  will  be  wide  mouthed  and  shallow,  at  other 
times  wide  mouthed  and  very  deep. 

Fact  No.  8.  Sometimes  pockets  are  very  numerous  but 
very  small  and  shallow  (this  is  especially  true  in  cases  of  at- 
rophy of  the  rectum),  in  other  cases  presenting  a  large  number 
of  pockets  that  will  be  both  long  and  large,  these  latter  being 
more  characteristic  in  cases  presenting  hypertrophy  of  tissues. 

Fact  No.  9.  In  children  rectal  pockets  are  more  numer- 
ous, as  a  rule,  than  they  are  in  grown  people,  suggesting  the 
thought  that  they  may  be  possibly  the  product  of  foetal  devel- 


272  ORIFICTAL   SURGERY. 

opment,  which  time  is  expected  to  eliminate  after  the  manner 
of  the  hymen,  the  adhesion  of  the  hood  of  the  clitoris,  and  the 
contraction  and  adhesion  of  the  foreskin;  in  which  case  they 
may  serve  to  explain,  as  suggested  by  Dr.  Holbrook,  one  of 
the  causes  of  hemorrhoids;  the  irritation  occasioned  by  the 
destruction  of  these  delicate  structures,  serving  to  induce  a 
congestion  of  the  blood  vessels  of  the  rectum. 

The  following  cut  illustrates  not  only  the  location  of 
pockets  but  also  the  manner  of  detecting  their  presence  by 
means  of  the  blunt  hook.  It  is  taken  from  the  first  edition  of 
my  work  upon  orificial  surgery. 


Care  must  be  taken  to  handle  the  instrument  gently  so  as 
not  to  perforate  the  bottom  of  the  pocket  in  making  an  ex- 
amination. The  presence  of  pockets  occasions  no  discomfort 
to  the  patient  and  they  are  therefore  wholly  unconscious  of 
their  existence.  One  or  more  must  be  badly  ulcerated  or  in- 
flamed, indeed,  to  be  the  seat  of  any  sensations  whatever,  as 
they  would  have  to  penetrate  far  enough  to  involve  the  ter- 
minal nerve  fibres  of  the  cerebro-spinal  system,  which  are  lim- 
ited in  their  distribution  to  the  margin  of  the  anus. 


ORIFICIAL   SURGERY.  273 

Fact  No.  10.  The  removal  of  rectal  pockets,  be  they  one 
or  a  dozen,  is  never  detrimental  in  the  slightest  degree  to 
the  health  or  happiness  of  the  individual ;  it  disturbs  no  func- 
tion, causes  no  inconvenience  or  disorder  of  either  the  rectum 
or  any  other  part  of  the  body. 

Fact  No.  11.  On  the  contrary,  it  is  the  unanimous  opin- 
ion of  those  who  are  in  the  habit  of  removing  rectal  pockets, 
and  they  are  now  a  large  army  of  operators,  that  the  practice 
is  universally  beneficial  to  the  functional  activities  and  health 
of  the  entire  body  of  the  patient  operated  upon. 

I  have  yet  to  learn  of  a  single  surgeon  who  has  once  en- 
gaged in  the  practice  of  removing  pockets  and  papillge,  to  ever 
in  the  slightest  degree  repudiate  the  practice.  But  on  the  con- 
trary, he  holds  it  in  high  esteem  as  his  experience  becomes 
more  extensive.  It  seems  as  though  the  testimony  of  these  gen- 
tlemen should  be  given  more  consideration  than  the  mere  the- 
oretical opinions  of  those  who  have  simply  talked,  but  not 
worked.  Experience  is  a  teacher  deserving  consideration. 

Fact  No.  12.  There  is  no  more  satisfactory  work  in  the 
whole  scope  of  medical  practice,  judged  by  the  standard  of 
health  and  satisfaction  enjoyed  by  the  patients,  than  the  re- 
moval of  rectal  pockets  from  those  who  are  unfortunate  enough 
to  possess  them. 

Fact  No.  13.  Contemporary  writers  upon  this  subject  who 
are  defending  the  extermination  of  pockets  on  the  ground  that 
they  are  anatomical  formations  and  should  be  permitted  to 
remain  unmolested  unless  in  an  ulcerated  condition,  display  by 
the  nature  of  their  remarks  that  they  have  never  been  in  the 
habit  of  removing  rectal  pockets  and  consequently  are  wholly 
ignorant  of  the  action  of  such  work ;  that  they  have  taken  their 
cue  from  the  so-called  authorities  upon  this  subject,  whom  we 
have  just  been  considering,  and  are  consequently  wholly  in- 
competent to  express  an  independent  and  reliable  opinion  upon 
the  subject.  They  owe  to  the  profession  an  apology  for  their 
presumptuous  writings,  and,  if  they  are  gentlemen,  they  will 
be  sure  to  make  it  before  another  decade  has  gone  by;  and  if 
they  are  not  gentlemen,  the  medical  world  will  soon  find  it  out 


274  ORIFIC1AL    SURGERY. 

and  give  little  heed  to  their  utterences.   Time's  debris  will  soon 
bury  them  out  of  sight. 

Conclusion.  In  view  of  the  preceding  facts  the  conclus- 
ion is  inevitable,  that  if  pockets  are  anatomy,  they  are  very  ir- 
regular, unreliable  and  useless  anatomy ;  and  that,  inasmuch  as 
their  removal  restores  their  possessor  to  health,  where  his 
bodily  functions  are  disordered,  they  are  bits  of  anatomy  which 
we  are  better  without  and  which  consequently  should  invari- 
ably be  dispensed  with. 

PAPILLAE. 

In  the  same  location  where  pockets  are  found,  namely,  at 
the  upper  border  of  the  internal  sphincter,  many  times  are 
seen  small  conical  projections  which,  from  their  shape,  are 
well  named,  papillae.  They  are  little  teats  which  vary  in  size 
and  length  from  the  point  of  a  pen  to  the  last  joint  of  the  lit- 
tle finger.  They  are  usually  transparent  at  their  tips  but  some- 
times are  club-shaped  and  even  bifurcated  and  without  trans- 
parency. They  usually  occur  singly,  although  sometimes  they 
appear  in  pairs,  in  such  cases  uniformly  presenting  the  mouth 
of  a  pocket  between  them.  I  have  been  able  to  find  them  men- 
tioned in  standard  medical  literature  in  but  two  or  three 
places  and  yet  they  are  very  common. 

A  few  magazine  writers  of  the  present  day  are  ignorant 
enough,  and  foolish  enough,  to  dub  these  anatomical  forma- 
tions, and  enter  into  an  active  debate  for  their  preservation. 
The  so-called  authorities  scarcely  mention  them.  Their  re- 
moval is  invariably  followed  with  very  marked  beneficial  re- 
sults to  the  patient,  whatever  may  be  the  nature  of  the  re- 
flex trouble  from  which  he  is  suffering.  These  two  conditions, 
pockets  and  papillae,  I  consider  the  most  mischievous  of  rectal 
troubles,  because  their  location  is  such  that  the  irritation  which 
they  occasion  induces  a  clonic  spasm  of  the  internal  sphincter 
muscles,  thus  inaugurating  a  perpetual  nerve  waste  of  the  sym- 
pathetic ;  and  no  work  in  surgery  is  so  magical  in  its  action,  so 
marvelously  effective  in  its  operation,  as  the  smoothing  of  this 
upper  border  of  the  last  inch  of  the  rectum,  by  removing  from 


ORIFI€1AL   SURGERY.  275 

it  all  pockets  and  papillae  which  it  presents ;  and  by  dilatation, 
removing  the  undue  muscular  tension  which  their  constant 
presence  has  occasioned. 

In  the  cut  which  illustrates  the  presence  of  the  blunt  hook 
in  a  pocket,  may  also  be  seen  three  small  papillae.  They  are 
never  above  or  below  this  line  of  union  between  the  skin  and 
the  mucous  membrane;  they  are  probably  hypertrophied  con- 
ditions of  the  papillary  layer  of  the  margin  of  the  skin  at  this 
point.  Their  removal  is  easily  effected  by  means  of  either 
tenaculum  or  forceps  and  a  pair  of  curved  scissors,  through  a 
speculum.  The  cut  shown  elsewhere  will  illustrate  what  I  be- 
lieve to  be  the  best  speculum  in  existence  for  purpose  of  ex- 
amination and  operation  upon  the  last  inch  of  the  rectum. 

The  normal  lining,  therefore,  of  the  last  inch  of  the  rec- 
tum is  perfectly  smooth  when  dilated  by  the  bivalve  speculum, 
presenting  neither  excavations  nor  prominences,  and  above 
passes  as  uninterruptedly  into  the  mucous  membrane  of  the 
middle  rectum  as  the  skin  passes  into  the  mucous  membrane 
at  the  margin  of  the  lips. 

As  a  thorough  discussion  of  the  entire  anatomy  of  the  rec- 
tum is  not  attempted  in  the  present  series  of  articles,  simply 
those  points  in  the  anatomy  and  physiology  of  the  part  will  be 
mentioned,  which  seem  to  the  writer  to  be  inadequately  or  er- 
roneously considered  in  the  standard  text-books.  Sufficient 
was  said  in  the  last  article  concerning  the  mucous  coat;  and 
the  remaining  two  coats,  the  cellular  and  muscular,  will  need 
but  brief  consideration. 

The  cellular,  sub-mucous  or  vascular  coat,  as  it  is  some- 
times called,  loosely  binds  together  the  mucous  and  muscular 
coats ;  so  loosely,  in  fact,  that  the  mucous  coat  is  capable  of 
a  considerable  degree  of  mobility  without  materially  disturb- 
ing the  muscular  structure — very  much  as  the  skin  can  be 
moved  quite  freely  over  any  part  of  the  body  without  dis- 
placing deeper  tissues.  The  cellular  coat  performs  the  same 
service  here  as  areolar  tissue  does  elsewhere  in  the  body.  It 
is  a  flexible  bond  of  union  between  adjacent  tissues,  and  also 
serves  as  a  nidus  for  blood  vessels,  nerves  and  lymphatics.  It 
can  thicken  and  bulge  with  the  products  of  congestion  or  in- 


276  ORIFICIAL   SURGERY. 

flammation,  or  it  can  flatten  and  waste  in  the  starvation  of 
atrophy.  Its  chief  ambition  seems  to  be  to  identify  itself  with 
whatever  may  be  the  tendency  of  the  other  structures  of  the 
rectum. 

There  is  only  one  anatomical  point  in  this  connection 
that  seems  to  call  for  consideration.  All  anatomists  agree  in 
their  description  of  the  lymphatics,  cerebro-spinal  and  sympa- 
thetic nerves,  and  the  arterial  and  venous  supply  of  the  last 
inch  of  the  rectum.  But  concerning  the  veins  of  the  hemor- 
rhoidal  inch,  I  believe  that  the  common  description  is  errone- 
ous in  one  particular. 

Gray  says:  "The  hemorrhoidal  plexus  surrounds  the  low- 
er inch  of  the  rectum,  being  formed  by  superior  hemorrhoidal 
veins  (branches  of  the  inferior  mesenteric)  and  the  middle  and 
inferior  hemorrhoidal  which  terminate  in  the  internal  iliac. 
The  portal  and  general  venous  systems  have  free  communica- 
tion by  means  of  the  branches  composing  this  plexus." 

Gray  omits  mentioning  the  fact  that  in  addition  to  these 
veins  there  is  a  system  of  veins  found  in  the  last  inch  of  the 
rectum  which  has  no  anastomosis  whatever  ^  with  the  veins 
which  he  describes.  They  start  in  blind  extremities,  thickly 
scattered  throughout  the  areolar  tissue  of  the  hemorrhoidal 
inch  and,  as  they  coalesce  above,  terminate  in  the  hemor- 
rhoidal plexus  which  he  describes. 

A  few  anatomists  jnake  mention  of  these  veins,  but  instead 
of  describing  them  as  possessing  a  uniform  caliber,  represent 
them  as  considerably  dilated  at  their  extremities,  resembling 
in  appearance  a  bunch  of  grapes.  This  I  believe  to  be  wrong. 
In  their  normal  state,  these  veins  are  of  uniform  caliber,  no 
larger  at  their  blind  extremities  than  where  they  Coalesce  to 
form  larger  veins. 

As  varicose  veins  in  the  lower  extremities,  in  the  sper- 
matic cord,  in  the  labia  majora  or  anywhere  else  in  the  body, 
have  crossed  the  boundary  lines  of  anatomy  and  become  path- 
ological, so  the  veins  under  consideration,  when  their  extremi- 
ties have  ceased  to  be  tubular  and  become  spheroidal  are  vari- 
cose and  therefore  pathological. 


ORIFIC1AL   SURGERY. 


277 


The  condition  commonly  described  as  hemorrhoids,  con- 
sists mainly  of  a  cluster  of  such  varicosities.  To  be  sure,  a 
hemorrhoidal  enlargement  contains  one  or  more  arterioles, 
one  or  more  enlarged  venous  canals  belonging  to  the  hemor- 
rhoidal plexus,  etc. ;  but  if  the  tumor  be  carefully  dissected, 


This  cut  illustrates  the  appearance  of  the  lower  rectal  veins,  which 
begin  in  (blinded  extremities,  after  they  become  varicose,  and  as  they 
occur  in  hemorrhoids.  Hemorrhoids  consist  mainly  of  clusters  of  these 
dilated  ends  of  veins,  imbedded  in  areolar  tissue.  An  occasional  author 
mistakes  these  for  anatomy;  but,  in  their  anatomical  condition,  these 
extremities  do  not  bulge  but  are  of  the  same  caliber  as  the  veins  of 
which  they  are  the  beginning. 

[This  cut  is  from  a  pen  sketch  by  Nils  Bergman,  M.  D.,  of  Lincoln 
Park  Sanitarium,  Chicago.] 

it  will  be  found  to  consist  mainly  of  a  cluster  of  these  dilated 
radicals,  we  are  considering,  varying  in  size  from  a  millet  seed 
to  a  marrowfat  pea.  There  are  sometimes  but  two  or  three  in 
a  single  hemorrhoid,  but  more  frequently  there  are  ten  or  fif- 
teen and  often  many  more  in  a  large  hemorrhoidal  tumor. 

These  enlarged  vein  terminals  lie  imbedded  in  the  areolar 
tissue  throughout  its  entire  thickness,  from  the  mucous  mem- 


278 


ORIFIG1AL    SURGERY. 


brane  to  the  muscular  structure,  and  are  as  carefully  packed 
in  it  as  eggs  in  a  box  of  sawdust.    They  are  scattered  every- 


VJ1M 


\'HE- 


P- 

Fig.  281. 

Rectal  veins  seen  from  without:  Amp.  rectal  pouch  or  ampulla;  P, 
skin  at  margin  of  anus  reflected;  SE,  external  sphincter;  VHE,  external 
or  inferior  hemorrhoidal  vein;  VHI,  internal  or  superior  hemorrhoidal 
vein;  VHM,  middle  hemorrhoidal  vein. 

This  cut  is  taken  from'  the  American  Text  Book  of  Surgery.  It  il- 
lustrates the  venous  anastomoses  of  the  last  inch  of  the  rectum,  but  in 
one  respect  is  incomplete.  The  superior  hemorrhoidal  veins  are  repres- 
ented as  starting  in  blinded  extremities.  This  is  partially  true;  but 
these  veins  also  anastomose  with  the  other  veins  and  the  blinded  ends 
should  extend  lower  down — as  far,  indeed,  as  the  internal  sphincter. 
Others  with  blinded  extremities  should  also  be  shown  still  lower  down, 
between  the  sphincters,  and  opening  into  the  other  veins. 

where  throughout  the  areolar  tissue  of  the  last  inch  of  the  rec- 
tum and  a  circle  of  them  is  often  found  completely  surround- 
ing the  circumference  of  the  rectum,  just  above  the  internal 
sphincter. 


ORIFIC1AL   SURGERY.  279 

Their  enlargement  in  this  position  constitutes  what  is 
properly  called  internal  piles.  Their  enlargement  in  the  are- 
olar  tissue  between  the  two  sphincters,  constitutes,  together 
with  the  other  morbid  structures  which  accompany  them,  what 
should  be  known  as  middle  hemorrhoids.  Only  when  pro- 
truding with  the  rest  of  the  hypertrophied  tissue,  below  the 
margin  of  the  anus,  are  they  properly  described  as  external 
hemorrhoids.  Sometimes  a  single  rootlet  of  this  class  of  veins 
becomes  dilated,  engorged  with  blood  which  soon  clots  and 
forms  a  small  hard  spot,  more  or  less  painful,  which  feels  to 
the  touch  of  the  finger  like  a  veritable  buckshot  covered  by 
the  mucous  membrane.  The  common  size  of  these  veinlets, 
when  their  hemorrhoidal  tendency  is  fairly  carried  out,  is 
about  that  of  a  grape  seed. 

This  subject  will  be  more  thoroughly  and  satisfactorily 
discussed  when,  in  this  series  of  articles,  we  come  to  the  spe- 
cial consideration  of  hemorrhoids,  which  at  the  present  time 
is  foreign  to  our  purpose. 

The  muscular  structure  of  the  last  inch  of  the  rectum 
consists  of  two  sphincters,  an  upper  and  lower,  which  guard 
respectively  its  two  extremities.  The  upper  sphincter  is  mere- 
ly an  aggregation  of  the  circular  fibers  of  the  muscular  coat 
of  the  intestine  and  is  dominated  by  the  sympathetic  nerve,  its 
fibers  being  of  the  involuntary  type. 

The  lower  sphincter  is  a  voluntary  muscle  and  consequent- 
ly supplied  by  the  cerebro-spinal  system  of  nerves.  An  ex- 
perience at  one  of  the  earlier  orificial  clinics  so  beautifully  il- 
lustrates this  point,  that  it  seems  worthy  of  narration  in  this 
connection.  The  patient  had  been  anaesthetized,  and,  desiring 
to  illustrate  the  action  of  rectal  dilatation  upon  the  respiration, 
I  requested  a  friend  present  to  dilate  the  sphincters  and  ob- 
serve the  effect  upon  the  breathing.  As  at  that  time  there  was 
no  good  speculum  for  purposes  of  dilatation,  the  gentleman  in- 
serted his  thumbs  and  forcibly  distended  the  anus. 

The  audience  present  had  been  hushed  to  silence  so  as  to 
watch  the  effect  of  the  dilatation.  Although  dilatation  was 
thoroughly  performed,  the  breathing  of  the  patient  was  not  in 
the  slightest  disturbed,  and  a  shade  of  disappointment  was 


280  ORIFIGTAL   SURGERY. 

seen  on  the  faces  of  the  spectators  as  well  as  upon  the  coun- 
tenance of  the  operator.  Not  satisfied  with  the  test,  the  op- 
erator himself  attempted  another  dilatation.  Instead  of  em- 
ploying his  thumbs,  however,  he  inserted  the  index  and  ring 
fingers  of  both  hands,  introduced  back  to  back,  and  far  enough 
to  secure  a  good  grip  upon  the  internal  sphincter.  Immedi- 
ately upon  spreading  the  fingers  the  expected  suspension  of 
respiration  occurred.  In  fact,  the  respiration  of  the  patient 
seemed  to  be  under  the  control  of  the  operator,  and  could  be 
suspended  or  liberated  at  will. 

The  evident  explanation  of  this  experience  was  simply 
that  the  invited  guest  with  his  thumbs  impinged  merely  upon 
the  fibers  of  the  external  sphincter  which  is  supplied  by  the 
cerebro-spinal  system,  while  the  operator  himself,  by  securing 
a  good  grip  upon  the  internal  sphincter,  appealed  to  the  sym- 
pathetic nerve,  and  thereby  influenced  the  respiratory  move- 
ment. The  experiment  was  repeated  several  times  in  this 
ease,  so  that  the  point  was  emphatically  established. 

It  is  not  possible  to  demonstrate  this  fact  in  all  cases,  as 
many  times  the  sympathetic  system  is  in  such  an  anaesthetic 
condition  as  to  be  incapable  of  responding  in  this  peculiar 
manner  to  even  extreme  dilatation. 

When  the  last  inch  of  the  rectum,  therefore,  is  in  a  nor- 
mal state,  its  internal  opening  at  the  upper  border  of  the  in- 
ternal sphincter  is  perfectly  smooth,  entirely  free  from  pock- 
ets, papillae  or  any  other  form  of  irritation,  and  presents  a  nar- 
row white  line  where  the  invaginated  skin  changes  to  mucous 
membrane. 

The  space  between  the  sphincters  presents  more  or  less 
deeply  reddened  color  above,  which  gradually  fades  into  the 
pale  skin  color  of  the  anus.  The  lower  opening  is  perfectly 
smooth  when  dilated,  and  thrown  into  very  fine  and  uniform 
folds  of  skin  when  contracted.  It  is  not  sensitive  to  touch,  and 
the  introduction  and  spreading  of  the  bivalve  speculum  can  be 
accomplished  without  pain. 

The  inch  contains  no  redundant  tissue,  no  spots  of  discol- 
oration, but  presents  over  its  entire  surface  a  uniform  color  as 
described.  A  distended  bivalve  renders  every  portion  of  it 
perfectly  smooth. 


ORIFIC1AL   SURGERY.  281 


CHAPTER  XXXV. 


RECTAL  SURGERY  FROM  AN  ORIFICIAL  STANDPOINT. 


E.   H.   PRATT,   M.   D. 


Normal  rectums  are  seldom  encountered  in  the  chronically 
sick.  The  reasons  for  this  we  have  endeavored  to  explain  in 
the  preceding  articles  of  this  series.  We  have  also  tried  to 
make  it  clear  that  the  restoration  of  the  rectum  to  a  normal 
condition  is  an  invaluable,  and  usually  a  necessary  element  in 
the  recovery  of  general  health. 

When  the  last  inch  of  a  rectum  is  in  a  pathological  condi- 
tion, the  sphincters  guarding  it  are  excited  to  undue  and  unre- 
mitting tension.  As  the  parts  which  are  unduly  pinched  are 
in  a  morbid  state,  double  nerve  waste  is  thus  involved :  the 
nerve  force  which  is  required  to  .keep  up  the  over-action  of 
the  sphincters,  and  the  exhaustion  arising  from  an  unremitting 
and  excessive  pinching  of  diseased  terminal  nerve  fibers. 

The  rectum  as  a  nerve  center  has  been  sorely  neglected 
by  our  medical  ancestry.  Never  until  the  last  few  years  was 
it  even  known  that  the  depth  of  inspirations  upon  which  all 
the  machinery  of  the  body  hinges  was  profoundly  affected  by 
rectal  conditions.  If  a  rectum  were  in  pain,  and  swollen  or 
sore,  it  could  command  the  attention  of  a  doctor  equally  with 
other  complaining  organs ;  but  the  idea  that  there  could  be  a 
painless  rectal  pathology,  shortening  respirations,  weakening 
peristaltic  actions,  inducing  sexual  irritability,  and  perpetu- 
ally sapping  the  vitality  of  the  entire  organism,  has  been  very 
foreign  to  the  medical  mind  of  the  past,  and  is  more  difficult 
than  it  should  be — in  some  cases  at  least — to  find  acceptance 
in  the  medical  mind  of  the  present.  But  such  is  the  case, 
nevertheless,  and  the  most  satisfactory  cases  in  the  practice  of 
orificial  surgery  are  those  which  have  never  complained  of 
rectal  troubles  and  present  no  symptoms  that  would  lead  the 
examining  physician  to  suspect  the  existence  of  any  form  of 
rectal  irritation. 


282  ORIFIOIAL    SURGERY. 

In  all  chronic  cases,  therefore,  the  rectum  should  be  care- 
fully examined  and  its  pathology  corrected,  whether  its  ab- 
normalities take  the  form  of  atrophy  or  hypertrophy,  hyperaes- 
thesia  or  ansescthesia,  and  whether  its  sphincters  present  un- 
due tension  or  undue  relaxation.  In  other  words,  it  is  high 
time  that  the  profession  appreciate  the  importance  of  rectal 
conditions  and  realize  that  the  testimony  of  the  patients  them- 
selves as  to  the  presence  or  absence  of  rectal  pathology  is 
perfectly  inconclusive  and  unreliable. 


RECTAL  BIVALVE. 


Those  who  have  never  systematically  examined  the  rec- 
tums  of  their  chronic  cases  must  be  prepared  for  a  good  many 
surprises,  not  only  as  to  the  unexpected  conditions  which  they 
will  encounter,  but  also  as  to  the  effects  which  they  will  pro- 
duce by  correcting  these  conditions. 

In  examining  a  rectum,  it  is  quite  common  for  doctors  to 
be  satisfied  with  what  they  are  able  to  ascertain  from  the 
sense  of  touch  by  the  mere  insertion  of  their  index  finger. 
This  common  practice  of  superficial  observation  is  scarcely  suf- 
ficient to  deserve  the  name  of  an  examination,  and  yet  it  too 
frequently  passes  for  such.  Such  a  procedure  may  diagnose 
hypertrophy,  but  it  could  scarcely  detect  the  more  profound 
pathology  of  atrophy.  It  could  disclose  the  inner  opening  of  a 
fistula,  perhaps,  or  a  row  of  papillae,  but  it  could  not  detect 
incipient  hemorrhoids,  or  rectal  pockets,  or  a  zone  of  sub- 
acute  inflammation  which  frequently  lines  the  last  inch  of  the 
rectum,  and  which  could  be  detected  only  by  the  sense  of  sight. 


ORIFIC1AL   SURGERY. 


283 


Those  who  are  just  beginning  their  acquaintance  with  rec- 
tal conditions  will  insist  upon  a  careful  examination  of  the 
rectum  before  they  feel  justified  in  placing  a  patient  under  an 
anesthetic  for  operative  procedures,  or  even  for  purposes  of 
examination.  Experienced  orificialists,  however,  feel  so  con- 


SHARP  a   SMITH    CHICAGO 


TENACULUM. 


fident  of  finding  some  form  of  rectal  irritation  in  those  who 
are  suffering  from  any  of  the  forms  of  chronic  disease,  that 
they  frequently  anaesthetize  a  patient  for  purposes  of  exami- 
nation, and  operation  if  deemed  necessary,  without  previous 
inspection,  realizing  that  rectal  dilatation,  as  it  flushes  the 
capillaries  of  the  entire  body,  institutes  nutritive  changes 
which  are  always  to  be  desired.  Anaesthetics  are  as  harmless 
in  orificial  work  properly  performed  as  they  are  in  parturition 
and  therefore  not  to  be  dreaded. 


ARTERY  IFORCEPS. 


Deeming,  then,  that  a  healthy  rectum  is  a  thing  to  be  de- 
sired, the  next  problem  which  confronts  the  doctor  is  how  to 
secure  it.  The  volunteers  in  the  form  of  remedial  measures  in 
a  rectal  campaign  are  numerous.  Mental  therapeutics  is  as 
ambitious  to  attack  sick  rectums  as  it  is  sick  stomachs,  sick 
headaches  and  other  physical  maladies.  Prescribers  of  drugs 
are  as  confident  that  they  can  cure  all  forms  of  rectal  disease 


284  ORIFIC1AL    SURGERY. 

as  they  are  that  their  drugs  are  adequate  to  all  other  bodily 
discords.  Magnetic  healers  would  attack  hemorrhoids  with  as 
much  confidence  as  they  would  lumbago,  insomnia  or  dyspep- 
sia. The  advocates  of  a  water  cure  would  expect  to  accom- 
plish everything  desirable  in  the  way  of  rectal  repair  by  ene- 
mata  and  compresses.  The  advocates  of  external  applications 
for  the  cure  of  human  ills  have  furnished  the  profession  with  a 
variety  of  rectal  ointments  worthy  a  World's  Fair  exhibition, 
and  the  hypodermic  syringe  would  feel  deeply  chagrined  if, 
after  its  achievements  in  the  relief  of  rectal  mischief,  it  should 
not  be  employed  when  a  rectum  needs  a  doctor. 


T  FORCEPS. 


Orificial  surgery  is  modest  in  some  respects,  and  is  willing 
to  wait  patiently  until  all  of  these  various  measures  have  been 
tried  and  proved  ineffectual  at  present.  It  is  no  farther  am- 
bitious than  of  being  the  last  resort,  but  it  does  demand  recog- 
nition and  a  fair  trial  before  a  case  of  chronic  disease  is  aban- 
doned as  hopeless. 

With  this  understanding  it  makes  no  apology  for  anes- 
thetizing a  case,  placing  it  in  the  dorsal  position,  with  the 
knees  well  flexed  upon  the  thighs  and  retained  there  either  by 
some  apparatus  or  by  assistants,  drawing  the  patient  down 
close  to  the  edge  of  the  table,  and  placing  opposite  the  operator 
a  tray  which  contains  a  rectal  bivalve,  a  blunt  hook,  two  or 
three  tenaculums,  a  dozen  or  more  artery  forceps,  eight  or  ten 
T  forceps,  a  probe,  a  grooved  director,  a  long  pair  of  scissors 


ORIFIC1AL   SURGERY. 


285 


curved  at  the  tip,  plug  forceps,  a  pair  of  Hall's  sigmoid  for- 
ceps, and  one  or  two  pairs  of  ordinary  tissue  forceps.  An- 
other tray  should  also  be  close  at  hand,  containing  absorbent 
cotton,  small  squares  of  sterilizzed  gauze  to  be  used  as 
sponges,  a  quarter  of  a  yard  of  antiseptically  prepared  China 
silk  and  a  T  bandage. 


GROOVED    DIRECTOR. 

Some  operators  would  suggest  a  few  additions  to  the  tray 
of  instruments,  in  the  shape  of  one  or  two  clamps  and  a  Pa- 
quelin  cautery.  As  in  the  course  of  time,  however,  these  sur- 
geons will  undoubtedly  learn  to  dispense  with  these  instru- 
ments, we  will  leave  them  out  now. 

The  use  of  the  various  instruments  mentioned  and  illus- 
trated will  appear  as  the  various  operations,  which  will  be 
called  for  in  rectal  surgery,  are  described. 

After  the  patient  is  anaesthetized  and  placed  in  position, 
it  is  proper  to  make  a  digital  examination  merely  to  determine 
the  presence  or  absence  of  strictures  and  tumors. 


LONG  CURVED  SCISSORS. 

The  rectal  bivalve  is  now  to  be  inserted  and  the  rectal 
tissues  exposed  and  carefully  examined  around  the  circum- 
ference of  the  last  inch.  This  examination  will  assist  in  de- 
termining the  form  of  operation  to  be  selected.  The  word 
"assist"  is  used  intentionally,  because  there  is  a  general  rule 
which  may  be  laid  down  as  a  safe  guide  in  a  large  majority  of 
cases ;  namely,  the  thoroughness  and  extent  of  the  operative 
procedure  should  depend  not  entirely  upon  the  local  condition 


286  ORIFIC1AL    SUKCiKKV. 

which  is  presented  but  be  influenced  somewhat  by  the  general 
condition  of  the  patient.  In  the  severer  forms  of  chronic  ail- 
ments, where  a  profound  effect  is  necessary  to  arouse  a  proper 
degree  of  reaction  throughout  the  system,  it  is  often  necessary 
to  replace  the  last  inch  of  the  rectal  mucous  membrane  with 
one  drawn  down  from  above,  although  the  appearance  of  the 
rectal  tissues  upon  examination  might  not  seem,  especially 
to  an  uneducated  eye,  to  warrant  so  severe  a  proceeding,  as  in 
such  cases  the  rectal  tissues  are  usually  pale  and  atrophied, 
and  so  completely  worn  out  as  to  occasion  an  extreme  degree 
of  nerve  waste.  And  yet  such  rectums  are  often  regarded  by 
those  who  should  know  better  as  perfectly  normal. 

On  the  other  hand,  it  is  quite  possible  to  handle  very  se- 
vere forms  of  local  mischief  in  the  shape  of  hemorrhoids,  fis- 
sures, pockets  and  papillae,  ulcers,  etc.,  without  resorting  to  a 
complete  removal  of  the  entire  pile-bearing  inch. 

The  more  delicate  the  case,  the  more  complicated,  pro- 
found and  remote  the  physical  disorder  from  which  the  pa- 
tient is  suffering,  the  more  necessary  it  is  to  completely  remove 
every  vestige  of  rectal  irritation  and  to  thoroughly  flush  the 
capillaries  of  the  body  and  appeal  as  strongly  as  possible  to 
the  latent  energies  of  the  system ;  whereas  in  cases  which  pre- 
sent a  condition  of  general  health  and  merely  some  severe 
form  of  rectal  disease,  the  extirpation  of  the  mucous  membrane 
of  the  last  inch  of  the  rectum  is  to  be  avoided  if  possible. 

It  is  important  to  settle  the  fate  of  this  last  inch  the  very 
first  thing,  because  the  form  of  operation  to  be  selected  will 
decide  at  what  stage  of  the  operation  dilatation  will  be  em- 
ployed. No  operation  should  be  performed  upon  the  rectum 
without  dilatation.  If  the  last  inch  is  to  be  sacrificed,  the 
dilatation  should  precede  the  operation.  But  if  it  is  to  be 
merely  smoothed  and  trimmed,  this  work  should  be  done  be- 
fore dilatation  is  practiced,  so  as  to  avoid  as  much  as  pos- 
sible any  swelling,  laceration  or  hematoceles,  which  would  be 
likely  to  be  induced  in  the  practice  of  dilating. 

There  is  another  point  of  value  in  determining  the  form 
of  operation  to  be  selected,  which  should  be  mentioned  in  this 
connection :  namely,  the  sensitiveness  of  the  patient  to  rectal 


ORIFIOTAL   SURGERY.  287 

dilatation.  There  are  cases  occasionally  encountered  in  which 
the  function  of  respiration  is  so  profoundly  affected  by  rectal 
dilatation  that  the  mere  introduction  of  the  closed  speculum 
will  produce  an  immediate  suspension  of  respiration.  There 
are  cases  where  a  rough  and  violent  use  of  the  rectal  speculum 
could  kill.  There  are  other  cases  which  are  so  profoundly 
anaesthetic  that  even  extreme  dilatation  of  the  anal  tissues 
will  produce  no  appreciable  effect  whatever  upon  the  respira- 
tory organs,  as  anaesthesia  is  a  deeper  seated  nervous  affection 
than  hyperaasthesia,  as  paralysis  is  a  graver  affection  than  ex- 
citability. The  cases  in  Avhich  there  is  no  appreciable  general 
response  to  rectal  dilatation,  as  a  rule  demand  more  thorough 
work  than  will  be  needed  to  do  justice  to  the  more  sensitive 
ones.  It  is  more  important,  therefore,  to  remove  the  last  inch 
of  the  rectum  in  conditions  of  anaesthesia  than  in  those  of  hy- 
peraesthesia  of  rectal  tissues,  regardless  of  the  apparent  rectal 
pathology  presented.  In  subjects,  therefore,  who  are  afflicted 
with  very  grave  affections,  be  they  tubercular,  glandular, 
syphilitic,  or  nervous,  if  the  function  of  respiration  be  quickly 
and  profoundly  affected  by  rectal  dilatation  it  will  probably 
not  be  necessary  to  renew  the  last  inch  of  mucous  membrane. 
But  if,  in  addition  to  a  serious  malady  of  some  other  part  of 
the  body  they  display  a  total  indifference  to  anal  dilatation, 
the  operation  upon  the  rectum  should  be  a  thorough  one,  per- 
fectly independent  of  the  appearance  of  the  tissues. 

There  are  severe  forms  of  rectal  disease  which  also  de- 
mand the  complete  removal  of  the  hemorrhoidal  mucous  mem- 
brane. Aggravated  cases  of  hemorrhoids,  with  excessive  hy- 
pertrophy and  prolapse  of  the  tissues,  are  best  treated  in  this 
way.  In  operating  upon  fistulas  in  ano,  it  is  usually  desirable 
to  remove  the  last  inch  of  mucous  membrane  from  the  rectum 
so  as  to  exterminate  the  other  rectal  pathology  which  always 
accompanies  this  condition,  and  at  the  same  time  effectually 
close  the  internal  opening  of  the  sinus. 

In  complete  laceration  of  the  perineum,  the  best  results 
are  secured  by  combining  the  perineum  operation  with  the 
removal  of  the  last  inch  of  the  rectum,  after  the  manner  de- 
scribed in  another  section  of  this  book  by  Dr.  W.  E.  Green.. 


288 


ORIFIG1AL    SURGERY. 


After  carefully  considering  all  these  questions  which  de- 
termine the  nature  of  the  operation  to  be  performed,  in  case 
it  is  decided  to  renew  the  hemorrhoidal  area,  the  first  step  in 
the  operation  should  be  a  careful  and  thorough  dilatation  of 
the  rectum  and  a  complete  cleansing  of  the  sigmoid  flexure  of 
the  colon.  This  is  best  accomplished  by  the  careful  handling 


PLUG  FORCEPS. 

of  the  rectal  bivalve.  First  in  order  is  dilatation  of  the  rec- 
tum. The  bivalve  is  to  be  inserted  with  the  handles  in  a  de- 
pendent position  and  the  blades  carefully  opened.  If  the  ef- 
fect upon  the  respiration  be  profound,  the  administration  of 
the  anaesthetic  should  be  stopped  and  the  speculum  removed. 
As  soon  as  the  stertorous  breathing  has  ceased  the  instrument 
can  be  again  introduced  and  dilatation  resumed.  Sensitive 


HALL'S  SIGMOND  FORCEPS. 

patients  should  always  be  carefully  watched  during  the  process 
of  dilatation,  and  also  given  ample  time  to  recover  from  its 
effects  before  the  work  is  again  proceeded  with.  The  system 
soon  becomes  somewhat  accustomed  to  the  action  of  the  specu- 
lum, so  that  even  in  these  sensitive  cases  the  profound  action 
of  the  dilatation  gradually  diminishes  and  enables  the  sur- 
geon in  a  short  time  to  accomplish  his  purpose  satisfactorily. 


ORIFIGTALr   SURGERY.  289 

The  manner  of  dilatation  is  to  be  determined  by  the 
amount  of  shock  desired,  remembering  that  every  time  the 
anus  is  opened  the  impulse  of  the  speculum  is  felt  throughout 
the  capillary  system.  If  the  case  be  sensitive  and  easily  af- 
fected, the  blades  of  the  speculum  should  be  opened  very 
slowly  and  carefully,  and  succussious  and  vibratory  motions 
with  the  instrument  dispensed  with.  But  if  the  case  be  a 
sleepy  one,  requiring  a  vigorous  shaking  up  to  awaken  a  gen- 
eral reaction  in  the  system,  the  dilatation  should  be  accom- 
plished by  a  succession  of  rapid  vibratory  motions,  which  are 
calculated  to  appeal  energetically  to  every  twig  and  branch 
of  the  circulatory  tree. 

In  all  dull  cases  it  is  perfectly  safe  to  dilate  to  the  ca- 
pacity of  the  bivalve,  as  this  degree  of  dilatation  seldom  pro- 
duces even  the  slightest  degree  of  paralysis  of  the  sphincters. 
Occasionally  cases  will  be  encountered  in  which  it  will  be 
found  necessary  to  supplement  the  action  of  the  bivalve  with 
the  employment  of  the  index  and  middle  fingers  of  each  hand, 
inserted  back  to  back  and  separated  until  in  the  judgment  of 
the  operator  a  proper  degree  of  dilatation  has  been  secured. 

The  cases  which  call  for  successive  dilatations  are  rare, 
but  are  met  with  in  two  classes  of  rectums  in  exactly  opposite 
conditions.  One  class  presents  such  a  distended  condition  of 
the  anal  tissues  that  the  complete  expansion  of  the  rectal  spec- 
ulum scarcely  puts  them  upon  tension.  They  are  cases  accom- 
panied with  prolapsus  of  the  rectum.  Dilatation  carried  to  the 
point  of  fairly  stretching  the  anal  tissues  will  induce  a  healthy 
reaction,  which,  with  subsequent  treatment  with  hot  douches 
and  electricity,  will  eventually  restore  the  parts  to  their 
proper  tone. 

Again,  sphincters  will  occasionally  be  encountered  so  ir- 
ritable and  yet  so  elastic  that  the  complete  expansion  of  the 
rectal  bivalve  fails  to  overcome  their  undue  tension,  and  as 
soon  as  the  instrument  is  removed,  even  after  it  has  been  held 
in  the  anus  completely  expanded  for  several  minutes,  they  will 
immediately  return  to  a  condition  of  spasmodic  stricture.  Such 
cases  also  call  for  a  more  thorough  dilatation  than  can  be  se- 
cured by  the  bivalve,  and  further  dilatation  can  be  effected 


25>0  ORIFIC1AL    SURGERY. 

either  by  the  fingers  after  the  manner  just  described,  or  by 
the  employment  of  Sims'  vaginal  specula.  It  is  fully  as  well 
in  such  cases  to  perform  sub-mucous  section  of  the  sphincters 
as  to  lacerate  and  bruise  the  parts  by  over-dilatation. 

The  manner  of  performing  sub-mucous  section  upon  the 
sphincters  will  be  described  in  a  later  article. 

The  dilatation  of  the  sphincters  is  now  to  be  followed  by 
thorough  cleansing  of  the  sigmoid  flexure  af  the  colon.  This 
is  to  be  accomplished  as  follows: 


TISSUE  FORCEPS. 

The  speculum  is  to  be  introduced  with  the  handles  down- 
ward and  closed.  The  handles  are  now  to  be  raised  and  the 
speculum  is  to  be  pushed  carefully  but  completely  into  the 
rectum  as  far  as  it  will  go  with  ease.  If  the  tissues  of  the 
middle  rectum  be  redundant,  and  the  progress  of  the  instru- 
ment obstructed  by  folds  of  the  upper  rectum,  while  the  right 
hand  is  gently  crowding  the  instrument  upward,  the  index 
finger  of  the  left  hand  is  to  be  introduced  on  the  upper  side  of 
the  rectum  and  sufficient  grip  secured  upon  the  sphincters  to 
straighten  the  rectum  sufficiently  to  permit  the  speculum  to 
-pass  well  into  its  cavity.  As  soon  as  the  instrument  refuses  to 
make  further  progress  in  the  direction  of  the  insertion,  the 
handles  are  now  turned  to  the  right  of  the  operator  and  the 
left  of  the  patient,  pressing  them  closely  against  the  but- 
tocks as  they  describe  the  first  quadrant  of  the  complete 
circle  which  they  are  ultimately  to  make. 

The  handles  are  now  to  be  carried  farther  on  in  the  same 
direction  until  they  press  against  the  perineum,  closely  hug- 
ging the  surface  of  the  skin  in  their  course.  If  the  speculum 
has  been  properly  handled  thus  far,  the  surgeon  should  now  be 
able  to  depress  the  handles  until  they  are  horizontal  with  the 
body,  quite  past  the  upper  extremity  of  the  rectum  and  into 
the  sigmoid.  The  termination  of  the  rectum  at  the  beginning 
of  the  sigmoid  is  so  much  narrower  than  either  the  rectum  or 
the  sigmoid  that  it  appears  to  be  guided  by  a  dilatable  sphinc- 


OKIPIC1AL   SURGERY.  291 

ter,  which  can  usually  be  recognized  as  the  speculum  passes 
through  it. 

Thus  far  the  blades  of  the  speculum  have  been  closed. 
The  hand  of  the  operator  is  now  placed  upon  the  handles  of 
the  speculum  and  the  blades  are  opened  more  or  less  thor- 
oughly, according  to  the  resistance  of  the  canal.  In  many 
cases  the  calibre  of  the  gut  will  be  so  small  as  to  permit  only  a 
slight  separation  of  the  blades.  In  other  cases,  the  blades  can 
be  opened  to  their  full  extent  without  the  slightest  resistance. 
Great  care  should  be  exercised  not  to  employ  force  in  opening 
the  blades  of  the  speculum,  but  to  desist  as  soon  as  resistance 
is  encountered.  After  the  blades  have  been  opened  they 
must  not  be  again  closed  until  the  speculum  has  been  complete- 
ly withdrawn.  After  opening  the  blades,  while  the  speculum 
is  in  the  sigmoid,  the  nozzle  of  a  fountain  syringe,  filled  with 
boracic  acid  solution,  is  to  be  introduced  into  the  rectum  and 
the  intestine  well  flushed.  By  a  gentle  vibratory  action  of  the 
blades  of  the  speculum,  secured  by  different  degrees  of  di- 
latation, the  sigmoid  can  thus  be  thoroughly  rinsed  and  all 
faecal  matter  and  mucous  which  it  contains  brought  away. 
The  speculum  is  to  be  withdrawn  either  by  completing  the  cir- 
cuit of  the  handles  or  by  returning  upon  the  original  semicircle 
which  they  described  during  the  introduction  of  the  instru- 
ment, care  being  exercised  to  keep  the  blades  wide  enough  to 
insure  against  any  pinching  of  the  rectal  tissues.  The  specu- 
lum can  be  introduced  in  this  manner  as  many  times  as  is  ne- 
cessary to  completely  evacuate  and  cleanse  the  sigmoid.  After 
this  has  been  accomplished,  it  is  well  to  introduce  the  specu- 
lum into  the  sigmoid  once  more,  spread  its  blades  as  previously 
described,  and  by  means  of  the  long  Hall  forceps  carry  a  rope 
of  antiseptically  prepared  wool  well  into  the  sigmoid.  This 
rope  should  be  six  or  eight  inches  lond,  and  be  secured  by 
a  string  fastened  about  its  lower  extremity  to  facilitate  re- 
moval. In  carrying  the  wool  into  this  position,  the  grooves  in 
the  speculum  must  be  remembered,  and  great  care  be  exer- 
cised to  use  no  violence  in  pushing  it  upward,  as  it  is  a  very 
easy  matter  to  puncture  the  intestine  by  even  the  slightest  de- 
gree of  violence. 


292  ORIFIC1AL   SURGERY. 

After  the  wool  has  been  well  packed  into  the  sigmoid  and 
rectum,  the  forceps  are  to  be  placed  against  its  lower  ex- 
tremity so  as  to  hold  it  in  position  while  the  speculum  is  be- 
ing withdrawn. 

The  process  just  described  is  known  as  packing  of  the 
rectum,'  and  is  just  as  serviceable  in  rectum  and  sigmoid  trou- 
bles as  dilatation  and  cleansing  are  in  the  male  or  female 
urethra,  in  the  vagina,  or  in  the  uterus.  The  wool  is  to  be 
removed  as  soon  as  the  last  inch  of  the  rectum  is  denuded  of 
its  mucous  membrane,  and  before  the  stitches  which  unite  the 
mucous  membrane  and  skin  are  separated,  in  cases  where  that 
procedure  is  undertaken,  but  may  be  left  in  position  for  a  day 
or  so  in  slit  work.  We  have  no  hesitancy  whatever  in  recom- 
mending this  measure  as  one  of  the  most  serviceable  in  the 
treatment  of  rectal  diseases.  We  have  employed  it  upon  sev- 
eral hundred  cases  and  have  never  yet  had  occasion  to  regret 
it.  It  does  not  weaken  the  gut,  but  strengthens  it.  If  there 
are  strictures  it  aids  in  overcoming  them.  If  there  is  an  ab- 
normal dilatation,  it  strengthens  the  gut  and  aids  it  in  re- 
turning to  its  normal  state. 

In  chronic  proctitis,  it  arouses  a  desirable  degree  of  re- 
action and  stimulates  recovery.  It  does  not  predispose  the  pa- 
tient to  invagination  of  the  intestine,  but  is  in  every  way  a 
valuable  and  commendable  procedure.  Having  employed  the 
measure  many  hundred  times  and  observed  no  harm  from  its 
use,  but  on  the  contrary,  universally  beneficial  results,  we 
have  no  hesitancy  whatever  in  recommending  the  measure  to 
the  profession  as  an  exceedingly  valuable  and  reliable  means 
of  strengthening,  cleansing  and  in  every  way  benefiting  the 
lower  part  of  the  large  intestine  immediately  above  the  anus. 
It  does  more  than  this,  because  the  nervous  connection  of  the 
sigmoid  is  exceedingly  extensive.  There  is  a  very  close  asso- 
ciation between  the  mucous  lining  of  the  sigmoid  and  the  blad- 
der in  both  sexes.  It  also  influences  profoundly  the  great  solar 
plexus  and  all  its  branches.  As  it  furnishes  a  reservoir  in 
which  the  faecal  matter  is  usually  carried  for  some  hours  be- 
fore it  is  precipitated  into  the  rectum,  it  is  very  liable  to  con- 


ORIFIC1AL   SURGERY.  293 

ditions  of  chronic  inflammation,  ulceration,  and  their  concomi- 
tants, abnormal  contraction  and  mucous  or  muco-purulent 
discharges. 

CHAPTER  XXXVI. 


HEMORRHOIDS. 


E.   H.   PRATT.   M.   D. 


Hemorrhoids  are  as  old  as  the  human  race,  and  so  is  their 
story.  But  in  the  present  article  we  shall  strive  to  avoid  serv- 
ing a  medical  hash  upon  the  subject  and  simply  present  some 
considerations  that  will  not  be  found  in  the  text-books — at 
least  to  our  knowledge.  The  text-books  of  this  and  past  gen- 
erations treat  exhaustively  of  the  nature  of  hemorrhoids,  of 
their  symptoms,  and  also  of  their  causes.  Hemorrhoids  which 
do  not  cause  local  symptoms  have  heretofore  been  regarded  as 
of  so  insignificant  a  nature  as  not  to  require  attention,  but  if 
they  induced  bleeding,  prolapsus,  pruritis  or  pain,  causing  the 
patient  sufficient  local  discomfort  to  induce  him  to  consult  a 
doctor  they  were  of  sufficient  importance  to  deserve  examina- 
tion and  treatment.  But  if  the  patient  was  always  questioned 
before  an  examination  was  instituted,  and  if  no  conscious 
symptoms  of  discomfort  were  elicited  no  local  examination  was 
deemed  necessary.  This  has  been  a  grave  error  on  the  part  of 
medical  men,  for  it  is  now  known  that  hemorrhoids  as  well  as 
other  pathology  of  the  last  inch  of  the  rectum  can  play  all 
manner  of  pranks  with  the  human  machinery  and  yet  cause 
no  local  discomfort  whatever.  An  examination  in  chronic 
cases  is  not  complete  without  an  examination  of  the  hemor- 
rhoidal  inch,  and  as  the  profession  has  made  the  mistake  of 
this  omission  so  long  it  is  high  time  a  reform  was  instituted, 
and  we  are  delighted  to  say  that  it  has  been  and  is  progressing 
with  remarkable  satisfaction  and  rapidity.  The  orificial  phil- 
osophy, although  it  is  still  young,  has  already  achieved  a  wide 
reputation,  and  has  taught  the  profession  a  good  many  les- 


294  ORIFIC1AL   SURGERY. 

sons  upon  this  subject  of  reflexes,  in  spite  of  the  fact  that  there 
is  still  a  large  army  of  medical  practitioners  who  still  remain 
unenlightened.  The  sale  of  rectal  specula  in  the  United  States 
within  the  last  ten  years  has  been  something  enormous,  and  it 
will  be  s'till  greater  in  the  next  ten.  The  instrument  makers  of 
Chicago  inform  me  that  the  sale  of  the  Pratt  trivalve  has  ex- 
ceeded the  sale  of  all  other  specula  combined.  However,  as  it 
has  long  since  been  superseded  by  a  better  one,  the  bivalve, 
this  latter  instrument  will  soon  undoubtedly  take  the  lead  in 
general  practice.  I  was  unable  to  find  a  good  rectal  speculum 
in  all  London  or  Paris,  and  as  the  surgical  shops  of  the  United 
States  abound  in  a  large  number  of  patterns  of  useful  instru- 
ments, it  is  but  natural  to  conclude  that  in  rectal  surgery 
Europe  must  learn  her  lessons  from  America. 

It  is  perfectly  proper  for  the  rectum  to  be  supplied  gener- 
ously with  veins,  but  when  they  become  sufficiently  dilated 
to  obtrude  themselves  on  the  attention  of  the  surgeon,  to  a 
sufficient  extent  to  be  classified  as  hemorrhoidal  structures, 
they  have  passed  the  bounds  of  anatomy,  have  become  path- 
ology and  call  for  surgical  interference. 

I  am  not  quite  satisfied  with  the  common  division  of  hem- 
orrhoids into  simply  external  and  internal,  by  external  mean- 
ing those  which  extrude  from  the  anus,  and  by  internal  those 
which  are  concealed.  It  is  much  more  convenient  to  divide 
them  into  three  classes,  and  I  am  in  hopes  that  this  classifica- 
tion will  be  universally  adopted :  namely,  internal,  middle  and 
external;  by  the  internal  meaning  those  which  are  above  the 
internal  sphincter,  by  middle  meaning  those  which  are  found 
between  the  two  sphincters,  by  external  those  which  protrude 
after  any  prolapsus  which  may  exist  has  been  restored.  In- 
ternal and  middle  hemorrhoids  may  protrude  in  cases  of  pro- 
lapsus, but  this  should  not  cause  them  to  lose  their  identity  be- 
cause they  can  be  easily  replaced,  and  we  desire  a  name  for 
those  which  cannot. 

One  naturally  infers  from  reading  the  common  descrip- 
tions of  hemorrhoids  that  dissection  of  these  tumors  has  not 
been  common  and  but  a  few  writers  describe  them  properly. 
In  another  chapter  will  be  found  cuts  and  a  brief  description 


ORIFIC1AL    SURGERY.  295 

of  the  veins  of  the  rectum,  from  which  a  correct  idea  as  to  the 
formation  of  hemorrhoids  can  be  gained.  It  will  be  seen  by 
referring  to  this  description  that  hemorrhoidal  structures  may 
be  merely  varicosities  of  continuous  veins  which  anastomose 
with  the  venous  network  of  which  they  are  a  part;  or  they 
may  be  a  mere  cluster  of  enlarged  terminal  veinlets  which  are 
peculiar  to  this  region  of  the  body.  In  any  case  a  hemorrhoid- 
al tumor  is  not  simply  one  large  vein,  but  a  bunch  or  cluster  of 
veins.  They  are  usually  accompanied  by  more  or  less  hyper- 
trophy of  the  areolar  and  mucous  tissue,  and  their  mucous 
surface  is  more  or  less  softened  and  disorganized.  It  is  im- 
possible that  such  a  surface  can  present  a  normal  condition  of 
terminal  nerve  fibres,  and  from  an  orificial  standpoint  this  is 
a  point  of  even  greater  value  than  a  mere  enlargement  of  the 
venous  structures  of  a  hemorrhoidal  tumor. 

The  mere  fact  that  the  veins  of  the  rectum  are  a  little  ab- 
normal in  size  is  a  matter  of  very  little  consequence  in  itself. 
But  the  additional  fact  that  the  abnormal  thickness  of  the  part 
induces  an  undue  and  continuous  tension  of  the  sphincters,  es- 
pecially of  the  internal,  and  that  the  abnormal  contraction  im- 
pinges upon  a  diseased  set  of  terminal  nerve  fibres  is  of  a  good 
deal  of  consequence. 

It  is  therefore  of  extreme  importance,  especially  in  cases 
of  reflex  trouble,  that  they  should  be  treated  surgically  rather 
than  medically,  as  medical  treatment  would  simply  reduce  the 
calibre  of  the  blood  vessels,  relieving  the  congestion  of  the 
part  somewhat,  but  would  not  cure  the  diseased  terminal  nerve 
fibres  of  the  part  involved.  The  extermination  of  the  tumors 
and  the  surface  covering  them  as  well  is  therefore  the  most 
satisfactory  treatment,  and  the  only  treatment  which  will 
yield  lasting  benefit  to  the  patient.  This  is  an  indirect  argu- 
ment against  the  employment  of  the  hypodermic  syringe  and 
of  the  common  practice  of  relying  upon  ointments  and  general 
medication  for  the  cure  of  hemorrhoids,  and  suggests  still  fur- 
ther that  even  thorough  dilatation  of  the  rectum  as  practiced 
by  Professor  Verneuil  of  Paris,  and  his  followers,  is  by  no 
means  sufficiently  radical  to  be  permanently  efficacious. 


29t>  ORIFIGiAL    SURGERY. 

TREATMENT. 

Extravagant  cases  of  hemorrhoidal  enlargements,  accom- 
panied by  protrusion,  may  call  for  one  of  the  three  methods 
previously  described  of  removing  the  entire  pile-bearing  inch 
and  renewing  it  with  tissue  brought  down  from  above;  these 
methods  being  the  clamp  operation,  the  English  operation 
and  the  American  operation.  But  if  the  general  health  of  the 
patient  is  all  that  could  be  desired  and  he  is  free  from  all 
forms  of  reflex  trouble  and  his  sufferings  are  merely  local,  it 
is  much  better  to  avoid,  if  possible,  the  entire  extermination 
of  the  last  inch  and  rely  upon  what  is  now  commonly  known 
as  the  slit  method  for  the  correction  of  the  hemorrhoidal  con- 
dition. This  method  is  perfectly  satisfactory,  and  sufficient 
for  all  cases  of  hemorrhoidal  affliction  except  the  most  aggra- 
vated ones;  and  as  the  recovery  from  the  slit  operation  is 
so  much  quicker,  the  after-treatment  so  much  simpler,  and  the 
appearance  of  the  rectum  ultimately  secured  so  much  more 
natural  in  every  way,  it  is  by  all  means  to  be  preferred. 

The  treatment  of  hemorrhoids  by  excision  has  always  been 
the  dream  of  the  profession,  the  only  objection  to  the  method 
and  the  only  reason  for  not  giving  it  the  preference  above  all 
other  methods  being  the  danger  of  hemorrhage. 

Most  of  the  text-books  were  written  before  the  days  of 
desirable  rectal  specula  and  of  T  forceps,  and  the  operators  of 
previous  years  had  not  yet  discovered  a  way  of  placing  the 
anal  tissues  at  the  command  of  the  operator  to  a  sufficient  ex- 
tent to  place  him  in  proper  command  of  the  situation  sur- 
gically. But  by  the  aid  of  the  improved  specula  of  late  years, 
of  T  and  artery  forceps,  and  the  knowledge  of  the  fact  that  by 
the  aid  of  these  instruments  the  bowel  tissues  can  be  easily 
everted  and  placed  entirely  at  the  command  of  the  operator, 
the  objection  to  the  treatment  by  excision  on  account  of  hem- 
orrhage is  completely  and  thoroughly  removed,  and  the  author 
of  rectal  surgery  of  today  who  ignores  this  fact  and  still  clings 
to  the  barbarous  practice  of  removing  hemorrhoids  by  ligature 
and  clamp  and  cautery  ought  to  be  ashamed  of  himself  and 
owes  an  apology  to  his  readers  for  what  must  be  either  his  ig- 
norance and  stupidity  or  else  his  bigotry  and  mulishness. 


OKIFIC1AL   SURGERY.  297 

The  medical  profession  would  esteem  it  poor  surgery  to 
amputate  a  limb  with  a  string  or  remove  a  tumor  by  ligation. 
If  they  wish  to  remove  a  limb  they  simply  cut  it  off,  stop  the 
hemorrhage  and  dress  the  wound.  If  they  attack  a  tumor  in 
other  parts  of  the  body  they  follow  the  same  sensible  plan  of 
simply  dissecting  it  out,  securing  the  blood  vessels,  and  end  at 
a  single  sitting  all  destructive  processes.  Why  they  should 
abandon  their  surgical  principles  and  choke  hemorrhoids  to 
death,  tying  with  their  cruel  strings  not  only  the  blood  ves- 
sels but  the  nerves  of  the  part  involved,  making  an  ugly 
slough,  inevitably  producing  an  unnecessary  degree  of  surgical 
shock  and  inviting  sepsis,  is  difficult  to  understand  when  it  is 
really  such  a  simple  matter  to  trim  hemorrhoids  away  neatly 
and  completely  at  a  single  sitting  and  without  the  slightest 
difficulty  or  danger. 

I  feel  that  I  am  not  doing  the  slightest  injustice  to  other 
methods  in  asserting  that  excision  of  hemorrhoids  in  ordinary 
cases  is  the  only  reliable  and  satisfactory  way  of  treatment. 
It  should  never  be  dangerous;  it  should  always  be  perfectly 
satisfactory  to  both  surgeon  and  patient  and  there  is  not  the 
slightest  excuse  for  longer  denying  it  its  proper  position  as  the 
best  treatment  for  hemorrhoids — that  is  middle  and  external 
hemorrhoids.  Internal  hemorrhoids  are  usually  accompanied 
with  more  or  less  prolapsus,  and  as  a  rule  call  for  the  removal 
of  the  last  inch  of  the  rectum  and  are  not  proper  subjects  for 
the  slit  method  as  slit  work  above  the  internal  sphincters  is 
unsafe.  External  hemorrhoids  are  either  acute  or  chronic. 

ACUTE  EXTERNAL  HEMORRHOIDS. 

The  acute  form  is  very  painful  and  presents  one  or  more 
small  tumors  just  outside  of  the  anal  orifice,  which  can  be 
seen  to  bulge  more  or  less  prominently  and  can  be  felt  to  be 
small,  round,  hard  bodies  varying  in  size  from  a  coffee  grain 
to  a  hazel  nut.  They  are  exceedingly  painful  to  the  touch,  and 
are  a  source  of  great  discomfort  to  the  patient  when  either 
sitting,  standing  or  walking.  They  are  in  reality  small  hsema- 
toceles,  existing  either  in  a  dilated  terminal  veinlet  or  lying 
embedded  in  the  areolar  tissue  as  a  result  of  a  rupture  of  the 


298  ORIFIG1AL    SURGERY. 

venous  coats.  The  treatment  for  these  is  very  simple  and  very 
satisfactory,  affording  immediate  and  permanent  relief  from 
all  soreness  and  pain.  They  simply  require  a  lancing  suffi- 
ciently free  to  permit  the  removal  of  the  clot.  A  curved 
pointed  bistoury  is  a  satisfactory  instrument  to  employ  for 
this  purpose,  and  as  soon  as  a  longitudinal  incision  is  made 
into  the  small  tumors  the  clot  can  easily  be  squeezed  out 
through  the  opening  or  dug  out  with  a  small  spud,  cuts  of 
which  instruments  are  here  appended.  It  is  well  afterwards 


to  apply  a  small  pledget  of  absorbent  cotton  moistened  with 
Pond's  Extract,  full  strength,  between  the  nates,  with  instruc- 
tions to  renew  it  each  day  for  two  or  three  days,  after  which 
it  can  be  dispensed  with.  No  confinement  of  the  case  is  neces- 
sary. 

CHRONIC  EXTERNAL  HEMORRHOIDS. 

Chronic  external  hemorrhoids  are  soft,  fluctuating,  venous 
tumors  about  the  anus,  unaccompanied  by  soreness  except  in 
cases  of  pruritus,  in  which  cases  the  soreness  is  not  due  at  all 
to  the  hemorrhoids  but  to  the  inflamed  condition  of  the  integu- 
ment. Sometimes  external  hemorrhoids  are  prominent  flabby 
structures,  and  sometimes  they  have  dwindled  to  such  an  ex- 
tent as  to  become  mere  shreds  of  doubled  integument  which 
dangle  about  the  anus,  causing  undue  activity  of  the  sebace- 
ous glands  and  occasionally  pruritis,  merely  from  the  redun- 
dancy of  the  tissue.  It  is  not  desirable  to  remove  them  unless 
the  patient  is  under  an  anaesthetic  as  they  are  not  in  them- 
selve  mischievous,  either  locally  or  generally,  and  their  re- 
moval without  an  anaesthetic  would  be  painful.  Almost  in- 
variably, however,  when  chronic  external  hemorrhoids  exist 
there  will  be  sufficient  pathology  within  the  anus  to  justify 


ORIFIGIAL   SURGERY.  299 

the  employment  of  an  anaesthetic,  and  while  the  internal  parts 
are  being  put  in  repair  these  chronic  external  excrescences 
should  always  be  smoothed  away  with  the  scissors.  The  cats 
should  always  be  made  radiating  from  the  centre  of  the  anus 
like  wheel  spokes  from  a  hub  and  a  sufficient  amount  of  tissue 
should  be  removed  to  leave  the  parts  nicely  and  smoothly  cov- 
ered after  the  wounds  have  healed.  It  is  plastic  work  and  calls 
for  a  quality  in  the  surgeon  which  if  directed  in  a  clothing 
line  would  have  made  him  a  tailor.  Through  the  wounds  in 
the  integument  the  underlying  nodules  of  hemorrhoidal  tissue 
will  appear  like  grape  seeds  embedded  in  the  areolar  tissue  and 
should  be  excised.  No  bleeding  of  consequence  will  occur,  and 
the  excision  should  be  carried  to  the  complete  extermination 
of  all  the  hypertrophied  and  hemorrhoidal  tissue.  No  speculum 
would  be  required  in  dealing  with  either  the  acute  or  chronic 
forms  of  external  hemorrhoids.  No  sutures  will  be  necessary. 

MIDDLE  HEMORRHOIDS. 

When  middle  hemorrhoids,  namely  those  existing  between 
the  two  sphincters,  are  to  be  treated  by  excision  some  form 
of  rectal  speculum  will  be  needed.  The  bivalve  is  by  far  the 
best  instrument  for  this  purpose.  There  are  two  kinds  of  mid- 
dle hemorrhoids,  which  may  be  classified  either  as  active  and 
passive  or  as  acute  and  chronic,  the  former  classification  per- 
haps being  preferable  because  in  the  term  acute  as  employed 
by  surgeons  is  usually  implied  an  active  process  of  inflamma- 
tion which  involves  pain  and  suffering,  which  is  not  true  of 
either  variety  of  middle  hemorrhoids. 

PASSIVE   MIDDLE  HEMORRHOIDS. 

After  the  speculum  is  introduced  into  the  rectum  and  di- 
lated to  a  sufficient  extent  to  thoroughly  smooth  out  the  mu- 
cous membrane  lining  the  last  inch,  distinct  tumors  of  a  pur- 
plish color  will  frequently  be  seen,  swelling  out  on  the  exposed 
rectal  surfaces,  protruding  prominently  into  the  field  of  vision 
perfectly  regardless  of  the  amount  of  dilatation  practiced. 
These  are  what  may  be  called  the  passive  or  chronic  middle 
hemorrhoids.  They  are  between  the  sphincters,  and  no  amount 
of  dilatation  seems  to  discourage  their  prominence. 


300  ORIFIG'IAL    SURGERY. 

ACTIVE  MIDDLE  HEMORRHOIDS. 

In  some  cases,  however,  after  the  speculum  has  been  in- 
troduced and  opened  widely  the  mucous  membrane  at  first  ap- 
pears perfectly  smooth  and  almost  normal  in  color.  Upon  re- 
laxing slightly  the  extreme  dilatation,  however,  and  waiting 
for  a  few  moments,  the  mucous  membrane,  which  at  first  ap- 
peared smooth,  gradually  begins  to  bulge  into  the  field  of  the 
speculum,  oftentimes  to  such  an  extent  as  to  cause  the  oppo- 
site sides  to  come  in  contact.  The  bulging  does  not  usually 
present  a  smooth  even  surface,  but  is  nodular  and  very  much 
in  appearance  like  small  brain  convolutions,  showing  distinctly 
the  large  veins  beneath  the  thin  covering  of  mucous  membrane. 
By  again  practicing  extreme  distension  the  surface  becomes 
smooth  and  all  hemorrhoidal  appearance  vanishes. 

For  hemorrhoids  of  this  nature  I  would  suggest  the 
name  active,  the  objections  to  the  term  acute  being  as  just 
stated.  Patients  who  are  troubled  with  this  form  of  hemor- 
rhoids usually  suffer  a  slight  prolapsus  at  stool,  which  is  read- 
ily corrected  by  pressure.  There  is  seldom  bleeding,  this 
symptom  being  confined  chiefly  to  the  chronic  and  more  promi- 
nent form. 

INTERNAL  HEMORRHOIDS. 

By  internal  hemorrhoids  are  meant  those  which  appear 
above  the  internal  sphincter.  From  the  internal  sphincter, 
pursuing  their  tortuous  course  upward,  under  the  mucous 
coat  of  the  rectum  will  occasionally  be  seen  numerous  large 
varicose  veins,  which  stand  out  like  cords  on  the  surface  of 
the  rectum  as  far  as  can  be  seen  through  the  field  of  the 
speculiL'i.  These  are  rare  cases,  occurring  mostly  in  old 
people,  and  are  usually  accompanied  with  enlargement  of  the 
veins  of  the  lower  extremities  (  scrotum  and  spemratic  cord,  or 
labia  majora,  as  the  case  may  be,  and  deserve  the  name  of 
hemorrhoids  simply  because  they  are  enlargements  of  the 
hemorrhoidal  veins.  Internal  hemorrhoids,  more  properly 
speaking,  are  hemorrhoidal  tumors,  varying  in  size  from  a 
split  pea  to  an  English  walnut,  which  cluster  around  the  bor- 
der of  the  internal  sphincter  and  which  are  formed,  like  the 


ORIFIC1AL   SURGERY.  301 

passive  middle  hemorrhoids,  of  clusters  of  over-dilated  venous 
terminals.  If  one  of  these  bunches  of  hemorrhoids  was  care- 
fully dissected  and  separated  from  the  connective  tissue  in 
which  it  is  imbedded  they  would  have  much  the  appearance 
of  a  blackberry,  the  dilated  extremities  or  veins  clinging  more 
or  less  closely  to  a  central  stem. 

These  internal  hemorrhoids  occur  in  cases  of  extreme  re- 
laxation and  atony  of  the  rectum,  characterized  by  more  or 
less  prolapsus  at  stool,  and  are  frequently  hemorrhagic. 

TREATMENT   OF  MIDDLE   HEMORRHOIDS. 

Whether  of  the  active  or  passive  variety,  middle  hemor- 
rhoids are  commonly  treated  by  a  great  many  rectal  specialists 
by  one  of  two  methods,  according  to  the  surgical  skill  of  the 
operator.  The  hypodermic  syringe  is  the  favorite  weapon  with 
which  these  structures  are  attacked  by  timid  and  unsurgical 
practitioners  in  diseases  of  the  rectum.  This  treatment  has 
one  advantage,  that  is,  that  it  can  be  employed  at  the  office  and 
does  not  necessitate  the  confinement  of  the  patient,  except  in 
occasional  instances,  in  which,  as  a  result  of  bad  judgment  on 
the  part  of  the  doctor  he  has  attacked  too  large  a  growth  or 
one  in  which  there  was  a  tendency  to  prolapsus  at  stool,  in 
which  case  the  grip  of  the  sphincters  prevented  the  return  of 
the  tumor  and  inaugurated  inflammatory  processes.  It  also 
occasionally  happens  that  the  puncture  has  been  made  too 
deeply  and  gives  rise  to  rectal  abscesses  and  other  unhappy  se- 
quelae. Those  who  practice  rectal  surgery,  however,  in  the 
proper  sense  of  the  term,  more  usually  prefer  one  of  two  meth- 
ods, which  are  described  and  endorsed  by  nearly  all  of  the 
text-books  upon  diseases  of  the  rectum,  namely,  ligation  and 
clamping. 

Another  method  of  treatment  which  is  somewhat  in  vogue 
should  also  be  mentioned,  namely,  dilatation  and  a  thorough 
kneading  and  bruising  of  the  hemorrhoidal  tissues  with  the 
thumb  and  fingers,  with  the  idea  of  instituting  some  acute  in- 
flammatory processes,  which  cause  subsequent  contraction  and 
more  or  less  complete  annihilation  of  the  hemorrhoidal  pro- 
jections. 


302  ORIFIC1AL    SURGERY. 

Prescribers  of  drugs  internally  and  advocates  of  heraor- 
rhoidal  ointments  are  usually  ambitious  to  try  their  skill  at 
exterminating  middle  and  internal  hemorrhoids.  If  such  doc- 
tors as  these  latter  can  stop  hemorrhage  and  correct  the  pro- 
lapsus they  lay  claim  to  a  cure,  because  the  external  evidences 
of  existing  hemorrhoids  have  disappeared,  and  they  have  no 
use  for  a  rectal  speculum. 

It  is  not  necessary  in  the  present  article  to  describe  these 
various  and  more  or  less  effete  measures — that  is,  effete  with 
those  who  have  learned  a  better  way — as  they  are  all  more  or 
less  unsurgical,  unsatisfactory,  and  should  be  supplanted  by 
the  only  perfectly  satisfactory,  safe,  and,  it  seems  to  me,  sen- 
sible way  of  annihilating  these  objectionable  growths,  namely, 

EXCISION. 

The  only  objection  that  has  been  raised  against  excision 
of  hemorrhoids  has  been  that  of  hemorrhage.  It  is  conceded 
that  the  removal,  by  some  process,  of  hemorrhoidal  growths  of 
the  middle  variety  is  not  only  desirable  but  imperative,  and  ex- 
cision would  be  by  far  the  most  desirable  manner  of  accom- 
plishing this,  could  the  danger  from  hemorrhage  ever  be  over- 
come. The  introduction  of  the  bivalve  speculum,  T  forceps 
and  tenaculum,  together  with  a  more  accurate  knowledge  of 
the  construction  of  hemorrhoidal  growths,  has  now  accom- 
plished this  desideratum.  And  as  this  operation  is  the  only 
one  which  receives  our  endorsement  in  cases  which  are  not  of 
sufficient  magnitude  to  call  for  the  American  operation,  we 
will  confine  our  description  of  operative  procedures  to  the 
process  of  excision. 

In  excising  external  hemorrhoids  all  redundant  tissue 
should  be  cut  away  level  with  the  skin  surface,  so  as  to  leave 
the  anus  smooth  and  free  from  redundant  tissue.  There  are  no 
large  nerve  trunks,  no  blood  vessels  of  any  considerable  size, 
and  no  muscles  that  are  endangered  by  such  a  proceeding,  and 
the  operator  can  shape  the  parts  to  his  liking  with  impunity. 

Not  so,  however,  with  the  middle  hemorrhoids.  If  he 
follows  the  same  plan  here  he  is  liable  to  wound  large  blood 
vessels  and  be  confronted  with  troublesome  hemorrhage,  and 


ORIFK-1AL   SURGERY.  303 

is  also  in  some  danger  of  cutting  through  the  muscular  coat 
of  the  intestine  and  endangering  the  tonicity  of  the  bowel  or 
making  possible  the  formation  of  a  subsequent  fistula. 

To  practice  excision  upon  middle  hemorrhoids  the  bivalve 
speculum  should  be  carefully  inserted  and  opened  just  wide 
enough  to  permit  the  hemorrhoidal  tissue  to  protrude  into  its 
field.  The  lower  end  of  the  hemorrhoid  to  be  operated  upon 
is  then  to  be  seized  with  a  tenaeulum,  which  should  not  be 
made  to  penetrate  deeply  into  the  tumor.  A  pair  of  surgical 
scissors,  curved  at  the  point,  may  then  be  employed  to  remove 
a  longitudinal  strip  of  mucous  membrane  from  the  hemor- 
rhoid along  its  entire  length.  The  cut  should  start  just  back 
of  the  grip  of  the  tenaeulum,  so  that  the  tenaeulum  remains 
attached  to  the  strip  to  be  removed.  The  blade  of  the  speculum 
should  now  be  opened  somewhat  wider,  so  as  to  spread  the  lips 
of  this  wound  while  the  operator  clips  away  with  the  scissors 
the  hemorrhoidal  tissue  which  protrudes  through  the  opening. 
By  holding  the  scissors  partly  open  and  pressing  with  the 
blades  upon  the  denuded  surface,  the  small  grape-like  projec- 
tions of  the  hemorrhoidal  structure  will  appear  between  the 
points  of  the  scissors,  and  can  then  be  clipped  off,  together 
with  the  redundant  areolar  tissue.  By  a  skillful  manipulation 
of  the  scissors  in  this  manner  the  entire  hemorrhoid  can  be 
removed  piecemeal  without  in  the  least  injuring  the  larger 
blood  vessel  underlying  the  tumor,  to  which  the  separate  parts 
of  the  hemorrhoid  are  tributary. 

Hemorrhoids  as  large  or  larger  than  the  end  of  one's 
thumb  can  in  this  manner  be  entirely  removed  without  the  loss 
of  any  considerable  amount  of  blood.  And  by  applying  this 
process  around  the  entire  circuit  of  the  anus  a  generous  crop 
of  hemorrhoidal  tissue  can  be  satisfactorily  and  successfully 
dispensed  withr.  The  larger  clusters  of  hemorrhoids  will  usu- 
ally be  found  on  the  sides  of  the  rectum  and  in  front  and  be- 
hind, there  usually  being  spaces  between  these  masses  which 
are  free  from  the  offending  structures. 

In  case,  through  accident  or  carelessness,  the  operator 
should  cut  deeply  enough  to  wound  the  underlying*  vein  or 
artery,  and  he  should  encounter  more  hemorrhage  than  he 


304  OKIFICIAL   SURGERY. 

expected,  it  is  a  simple  matter  to  seize  the  blood  vessel  with  a 
pair  of  artery  forceps,  which  are  to  be  left  dangling  from 
the  wound  while  the  rest  of  the  circumference  of  the  anus  is 
being  examined  and  operated  upon.  One  or  two  minutes  is  a 
sufficient  length  of  time  to  leave  the  artery  forceps  in  position 
if  they  are  constructed  sufficiently  strong  to  crush  the  tis- 
sues. Ligature  of  the  anal  blood  vessels  is  almost  never  ne- 
cessary, as  the  hemorrhage  is  very  easily  and  speedily  con- 
trolled by  artery  forceps  at  the  time  of  the  operation  and  sub- 
sequent hemorrhage  is  so  insignificant  as  to  require  no  at- 
tention whatever. 

Great  care  should  be  taken  in  this  operation  to  avoid 
denuding  the  entire  circumference  of  the  last  inch  of  its  mu- 
cous membrane.  At  least  three  or  four  strips  should  be  left 
unmolested.  It  matters  little  how  narrow  they  are  so  long 
as  their  continuity  is  undisturbed.  It  is  remarkable  to  what 
extent  the  last  inch  of  the  rectum  can  be  denuded  of  its  mucous 
membrane  with  impunity  if  one  is  simply  careful  in  this  par- 
ticular. Subsequently  the  mucous  membrane  seems  to  grow 
from  the  margins  of  the  unmolested  strips,  and  is  reproduced 
so  perfectly  as  to  leave  scarcely  a  trace  of  the  surgical  pro- 
cedure. 

Greater  care  must  be  exercised  in  operating  in  this  way 
upon  active  than  upon  passive  hemorrhoids. 

The  large  purple  and  protruding  tumors  that  fall  into 
the  field  of  the  speculum  as  soon  as  it  is  opened  have  little  ten- 
dency to  bleed,  and  the  operator  is  usually  surprised  in  his 
first  experience  to  find  with  what  impunity  he  cah  dissect 
these  structures  away,  with  the  loss  of  but  a  few  drops  of 
blood. 

The  active  hemorrhoids,  however,  which  disappear  when 
the  speculum  is  widely  opened,  and  which  gradually  fill  with 
blood  after  it  has  been  partially  closed  and  held  in  position 
for  a  short  time,  had  better  be  handled  a  little  more  cautiously, 
as  they  consist  of  less  of  what  may  be  called  the  grape-seed 
structure  and  owe  their  existence  to  excessive  dilatation  of 
the  single  veins  or  arteries.  Hemorrhoids  of  this  class,  which 
we  have  called  active  hemorrhoids,  will  bleed  more  or  less  pro- 


ORIFIC1AL   SURGEEY.  305 

fusely  in  the  process  of  excision,  and  the  artery  forceps  will 
quite  frequently  be  called  into  requisition.  It  is  unnecessary, 
however,  in  any  variety  or  extent  of  hemorrhoids  to  lose  any 
considerable  amount  of  blood  in  the  process  of  complete  extir- 
pation by  this  method,  which  is  now  known  as  the  slit  method. 

All  of  the  cuts  in  the  mucous  membrane  are  made  longi- 
tudinally with  the  intestine,  and  the  lower  margin  of  the  cut 
must  be  carried  down  as  low  as  the  anus,  as  the  hemorrhoidal 
structures  usually  extend  to  this  point;  and  in  cases  where 
they  do  not  the  parts  heal  better  if  the  wound  starts  at  the 
anus.  It  is  well  to  make  the  circuit  of  the  anus  with  the 
speculum  two  or  three  times  as  in  the  first  time  around  the 
operator  is  very  apt  to  overlook  one  or  more  hemorrhoidal 
rootlets,  which  if  left  unmolested  would  permit  a  reappearance 
of  the  tumors,  although  on  a  much  smaller  scale.  After  the 
hemorrhoids  have  been  entirely  excised  the  anus  should  be 
thoroughly  dilated  with  the  bivalve,  care  being  taken  not  to 
do  this  with  sufficient  violence  to  tear  the  sphincter  muscles. 
Should  this  accident  happen  the  muscle  gives  away,  almost  In- 
variably at  its  posterior  aspect,  and  by  denuding  the  surface 
of  the  mucous  membrane  at  this  point  it  can  be  very  easily 
stitched  together,  a  proceeding,  however,  which  is  very  sel- 
dom called  for. 

The  bivalve  speculum,  the  T  forceps,  by  means  of  which 
the  parts  can  be  seized  and  brought  well  into  view,  and  the 
artery  forceps,  have  robbed  the  excision  operation  entirely  of 
all  danger  of  hemorrhage,  and  placed  it  when  it  does  occur 
so  completely  at  the  control  of  the  operator  that  this,  the  only 
objection  to  the  excision  process,  is  now  entirely  overcome ; 
and  there  is  no  longer  any  excuse  on  the  part  of  rectal  sur- 
geons for  indulging  in  what  should  be  obsolete,  and  what  is 
the  barbarous  and  unsurgical  practice  "of  treating  hemorrhoids 
by  either  injection,  clamp,  ligature  or  bruising  processes. 
Where  the  patient  is  free  from  reflex  disturbances  and  merely 
suffers  the  local  inconvenience  of  middle  hemorrhoids  no  other 
operative  procedure  will  be  called  for,  and  the  rectal  surgeon 
who  handles  the  excision  process  with  merely  ordinary  skill 
will  be  so  pleased  with  the  ease  and  success  of  the  method  as. 


306  ORIFIG1AL    SURGERY. 

to  willingly  employ  it  in  lieu  of  all  others.  What  hemorrhage 
is  occasioned  by  the  operation  occurs  in  the  presence  of  the 
operator  and  is  placed  under  his  easy  control  by  the  aid  of  the 
instruments  already  mentioned.  No  stitching  is  required,  no 
subsequent  attention  is  necessary  except  what  is  necessary 
to  keep  the  parts  in  a  cleanly  state  while  undergoing  the  pro- 
cess of  healing.  It  dispenses  with  the  formation  of  abscesses, 
the  unwholesome  process  of  sloughing,  and  all  of  the  ob- 
jectionable features  of  the  other  methods  referred  to. 
TREATMENT  OF  INTERNAL  HEMORRHOIDS. 

These  are  above  the  internal  sphincter,  and  consequently 
must  be  handled  with  greater  care,  as  the  circular  fibres  of  the 
rectum  just  above  the  sphincters  will  not  contract  sufficiently 
to  control  the  hemorrhage  should  accident  or  necessity  in- 
volve it. 

As  internal  hemorrhoids  are  usually  accompanied,  how- 
ever, with  more  or  less  prolapsus,  they  almost  invariably  de- 
mand the  American  operation  for  their  extermination,  and  the 
process  of  excision  is  not  so  well  adapted  for  their  treatment 
as  it  is  for  hemorrhoids  of  the  middle  variety.  Although  per- 
sonally we  frequently  employ  this  same  process  of  excision 
for  internal  hemorrhoids,  we  are  loath  to  recommend  it  as  a 
general  practice  for  fear  that  some  operator  in  cutting  a  little 
too  deep  or  unskillfully  will  have  occasion  to  regret  its  em- 
ployment. Internal  hemorrhoids  are  best  treated  by  the 
American  operation. 

CHAPTER  XXXVII. 


THE  SLIT  OPERATION. 


CORA    SMITH    EATON,    M.    D. 


The  slit  operation  is  Dr.  Pratt 's  modification  of  the  old 
method  of  excision  of  hemorrhoids. 

Indications.  1.  Where  there  are  scattered  pile  tumors 
of  the  middle  and  external  variety  not  involving  the  entire 
inch. 


ORIFIC1AL   SURGERY.  307 

2.  Where,  perhaps,  the  whole  inch  is  seriously  affected 
but  the  tissues  are  so  stiff  or  so  friable  that  elasticity  and 
strength  are  lacking  to  allow  pulling  down  of  the  tissue  to 
cover  the  denuded  inch  as  required  by  the  American. 

Contra  Indications.  1.  When  the  entire  inch  is  involved 
and  the  tissue  thickly  padded  with  enlarged  veinlets.  These 
cases  will  be  difficult  to  clear  up  by  slit  operation  and  require 
the  complete  American. 

2.  Where  there  is  extravagant  hypertrophy  of  tissue  in- 
volving the  entire  inch.    Here,  also,  the  American  or  clamp  is 
required. 

3.  Where  there  are  internal  hemorrhoids,  that  is,  those 
located  above  the  clasp  of  the  internal  sphincter.     The  conse- 
quent  liability   to    hemorrhage    indicates    an    operation   with 
sutures  as  in  the  American. 

Preparatory  Treatment.  The  day  previous,  give  light 
diet,  laxative,  and  thorough  flushing  in  knee  chest  position. 
The  day  of  the  operation,  repeat  the  flushing  and  allow  no 
food. 

Instruments.  The  instruments  needed  are  rectal  bivalve 
speculum,  sharp  hook  or  tenaculum,  short  curved  scissors,  T- 
forceps,  artery  forceps,  full  curved  needle  and  holder,  silk 
and  catgut  sutures. 

Description.  The  operative  technique  is  as  follows:  A 
thorough,  but  gentle,  intermittent  dilatation  of  the  sphincter, 
with  the  rectal  bivalve,  should  be  practiced  until  the  muscle 
is  well  relaxed.  The  rectal  speculum  is  now  inserted  and 
opened  to  expose  the  hemorrhoidal  inch,  first  antero-poster- 
iorly,  and  then  withdrawn  and  reinserted  for  the  lateral  por- 
tions. 

The  operation  may  be  done  with  the  speculum  thus  held 
by  an  assistant ;  but  easier  yet  is  to  dispense  with  the  speculum 
after  the  slit  is  made  and  seize  the  anal  margin  with  T-forceps 
and  evert  the  inch  over  the  left  forefinger,  thus  doing  the  work 
quite  outside.  The  first  incision  is  the  slit  which  gives  the 
operation  its  name.  A  sharp  hook  picks  up  the  mucous  mem- 
brane over  a  pile  tumor,  and  a  pair  of  short  curved  scissors 
removes  a  narrow  strip  1-16  inch  wide,  extending  from  the 


308  ORIFIG1AL    SURGERY. 

anal  verge  to  the  upper  margin  of  the  hemorrhoid.  Always 
begin  this  slit  at  the  lower  margin  of  the  anus,  even  if  the 
hemorrhoid  is  quite  far  up,  as  the  healing  is  much  better. 
Next,  by  opening  the  speculum  wide  or  by  pushing  the  hemor- 
rhoid up  through  the  slit  with  the  left  forefinger,  over  which 
the  membrane  is  pulled  down,  the  slit  stretches  open,  and 
the  enlarged  veinlets  are  then  easily  snipped  off  with  the  scis- 
sors. The  areolar  tissue  and  all  are  to  be  cleanly  removed 
down  to  the  muscle.  There  is  no  excuse  for  wounding  the 
sphincter  muscle,  for  it  can  be  plainly  felt  as  an  elastic  but 
resisting  band  by  the  left  forefinger  underneath.  By  chang- 
ing the  position  of  the  speculum,  or  by  pulling  down  new  sec- 
tions with  T-forceps,  the  entire  circumference  of  the  inch  is 
thus  gone  over,  and  each  pile  tumor  treated  through  a  new 
slit. 

If  necessary,  the  slit  may  be  made  an  inch  wide,  and  the 
underlying  tissue  cut  out  thoroughly  down  to  the  sphincter. 
The  undisturbed  strips  between  the  slits  need  be  only  one- 
quarter  to  one-sixteenth  of  an  inch,  and  only  four  or  five  in 
number  so  long  as  they  are  straight,  and  left  in  perfect  con- 
tinuity from  the  anal  margin  to  the  internal  sphincter,  "like 
spokes  in  a  wheel."  If  there  is  hemorrhoidal  tissue  under 
them,  the  strip  can  be  pulled  aside  by  a  sharp  hook  and  all 
veinlets  and  areolar  tissue  removed,  and  still  the  reproduc- 
tion of  the  mucous  membrane  lining  the  hemorrhoidal  inch 
will  be  perfect.  It  is  wonderful  how  the  surface  renews  itself. 

All  hemorrhage  is  easily  controlled,  as  it  is  all  in  view, 
thanks  to  T-forceps  and  rectal  dilatator.  Only  spurting  ves- 
sels need  be  noticed,  and  they  will  be  closed  by  pressure  of 
artery  forceps  for  two  or  three  minutes.  After  the  operation 
is  done,  the  natural  contraction  of  the  sphincter  stops  all 
oozing  within  its  clasp — the  only  hemorrhage  which  can  come 
after  the  operation  is  finished  will  come  from  arteries  above 
the  internal  sphincter,  and  careful  examination  will  disclose 
any  such.  A  catgut  stitch  embracing  the  vessel  will  insure  no 
further  trouble. 

After  removing  all  middle  hemorrhoids,  allow  the  everted 
inch  to  return  within  the  grasp  of  the  sphincter,  and  remove 


OElPIGlAL   SURGERY.  300 

all  external  hypertrophy  by  lifting  each  bunch  with  the  ten- 
aculum  and  cutting  it  off  clean.  There  are  no  arteries  here  to 
bleed,  and  nature  will  quickly  cover  up  the  denuded  surface. 
The  respiration  may  be  affected  by  the  dilatation  with  the 
speculum  or  by  the  pinching  of  the  T-forceps.  In  such  cases 
remove  the  instrument  and  anesthetic  as  soon  as  breathing 
becomes  labored,  and  give  the  patient  a  moment  to  recover 
from  the  shock.  You  can  soon  proceed  without  trouble.  As  a 
rule,  each  pile  removed  seems  to  lighten  the  burden  of  re- 
flexes, and  the  patient  breathes  easier  as  if  thankful  for  one 
more  sorrow  lifted.  No  sutures  are"  needed. 

Dressing.  A  tight  roll  of  sterilized  gauze  the  size  of  the 
thumb  is  smeared  with  calendula  cerate  and  placed  in  the 
grasp  of  the  sphincters,  with  a  silk  cord  tied  to  the  protruding 
end  to  facilitate  removal.  This  plug  stimulates  natural  con- 
traction and  applies  a  healing  medicament.  Powdered  boracic 
acid  should  be  sprinkled  freely  over  the  anus  and  a  pad  of 
cotton  and  gauze  held  snugly  against  the  parts  by  T-bandage. 
The  plug  is  left  not  longer  than  an  hour,  and  removed  sooner 
if  the  breathing  is  not  satisfactory,  or  if  the  patient  awakens 
sufficiently  to  complain  of  the  pain.  Its  removal  may  cause  a 
momentary  pang,  but  relief  follows. 

After-treatment.  Keep  the  parts  smeared  with  calendula 
cerate  and  powdered  with  boracic  acid.  Pain  will  be  en- 
countered in  only  a  few  cases.  It  is  promptly  controlled  by  a 
spray  from  the  fountain  syringe,  using  two  quarts  of  calen- 
dulated  water  (one  teaspoonful  to  the  quart),  hot  as  can  be 
borne,  repeated  as  frequently  as  required.  Cham.  3x  or  hyper. 
3x  given  internally  every  five  minutes  sometimes  acts  magic- 
ally. If  pain  persist,  %  gr.  morphia  should  be  given  hypo- 
dermically. 

The  patient  is  kept  in  bed  a  week.  Liquid  diet  until  after 
the  first  stool,  which  is  allowed  on  the  fourth  or  fifth  day.  The 
stools  must  be  made  soft  by  mild  laxative  and  lubricated  by 
4  oz.  of  sweet  oil  given  per  rectum  half  an  hour  before  the 
enema.  Pain  following  the  stool  should  be  treated  like  that 
following  the  operation.  Daily  stool  by  enema  thereafter  un- 
til natural  movement  is  possible.  Then  healing  will  be  facili- 


310  ORIFICIAL  SURGERY. 

tated  and  comfort  secured  by  having  the  patient  use  every 
night  for  about  two  weeks  a  rectal  suppository  of  aesculus, 
haraamelis  and  hydrastis. 

Advantages  and  Disadvantages.  The  advantages  of  the 
slit  operation  are  simplicity,  rapidity,  and  comparative  pain- 
lessness,  from  the  fact  that  no  sutures  are  used.  The  disad- 
vantages are  only  such  as  arise  from  imperfect  work.  First 
and  chief,  liability  to  recurrence  by  reason  of  the  incomplete 
removal  of  hemorrhoidal  tissue  is  the  chief  one.  A  secondary 
operation  will  remedy  this. 

Second:  Hemorrhage  never  met,  except  as  the  result  of 
carelessly  wounding  and  overlooking  blood-vessels  above  the 
internal  sphincter. 

My  operations  for  hemorrhoids  number  forty-two,  the 
American  or  clamp  eleven  and  the  slit  operation  thirty-one. 
In  the  thirty-one  slit  cases  I  have  had  satisfactory  results  with 
the  following  exceptions : 

1.  Hemorrhage,  one  case,  from  a  cut  above  the  internal 
sphincter,  overlooked  after  dilatation.     Patient  had  stools  of 
blood  every  hour  or  so  from  1  p.  m.  till  10  p.  m.,  when  it 
was  reported  to  me.     She  was  much  weakened  by  this  time. 
Chloroform  was  given  immediately,  and  I  closed  the  gap  with 
catgut  sutures.     Subsequent  recovery  without  incident. 

In  only  three  cases,  during  operation,  did  I  deem  it  neces- 
sary to  use  sutures  or  ligatures  to  prevent  possible  hemor- 
rhage. 

2.  Recurrence,    four   cases,   requiring   secondary   opera- 
tion.    Three  of  these  cases  were  probably  due  to  insufficient 
removal.     The  fourth  was  from  an  error  in  judgment  in  not 
using  the  American  in  the  first  place.    This  patient,  even  since 
her  second  operation,  though  now  in  good  health  and  previ- 
ously an  invalid,  never  fails  to  tell  me  she  "still  has  piles," 
meaning  rectal  sensitiveness  and  occasional  pain  after  stool, 
though  no  prolapsus.     Careful  after-treatment,  which  she  re- 
fused to  take,  might  suffice.     The  American  would  settle  the 
matter  forever. 


ORIFICIAI,  SURGERY.  311 


CHAPTER  XXXVIII. 


SLIT  OPERATION  UNDER  COCAINE. 


CORA    SMITH    EATON,    M.    D. 


There  are  many  cases  presenting  symptoms  of  local  dis- 
comfort and  of  sympathetic  disturbances  in  other  parts  of 
the  body,  from  hemorrhoidal  growths.  Some  of  these  patients 
cannot  afford  either  the  time  or  the  money  for  an  ideal  surgical 
removal  of  the  hemorrhoids  at  the  hospital.  It  taxes  our  in- 
genuity to  relieve  these  patients  while  conforming  to  their 
conditions.  Several  of  these  have  been  treated  at  my  office 
with  gratifying  results  after  the  method  described  in  the  fol- 
lowing case: 

Mrs.  A.  M.  L.,  aged  45,  past  the  climacteric,  no  lacera- 
tion, but  a  tendency  to  prolapsus  of  all  pelvic  organs,  although 
the  uterus  retained  its  normal  anterior  curve.  She  came  be- 
cause of  vesical  irritation,  evidently  gonorrheal,  which  sup- 
position was  later  confirmed  by  confession  of  her  husband, 
who  is  a  traveling  man.  There  was  much  tenesmus,  urging 
oozing  of  greenish  discharge  from  the  urethra,  general  bear- 
ing down  and  aching  of  hips  and  external  genitals,  extending 
into  the  thighs.  The  bladder  trouble  was  completely  cured  in 
about  six  weeks  by  hydrozone  irrigation,  two  teaspoonfuls  to 
the  quart,  and  by  cantharis  Ix  internally.  The  uterus  was 
also  propped  up  by  hydrastis  cerate  tampons,  and  eventually 
retained  its  normal  height  in  the  pelvis.  Notwithstanding  this 
improvement,  the  aching  m  the  genitals  and  thigh  continr-ti, 
and  made  her  life  a  burden.  As  a  last  resort  I  carefully  ex- 
amined the  rectum  and  found  internal  hemorrhoids.  Placing 
the  bivalve  speculum  in  the  rectum,  with  patient  in  the  knee- 
chest  position  to  throw  a  good  light  into  the  field  of  operation 
and  make  it  more  accessible,  I  selected  two  pile  tumors  for  the 
first  treatment,  and  injected  into  each -one  about  four  minims 
of  a  4  per  cent,  solution  of  cocaine,  freshly  prepared  from 
P.  D.  &  Co.  tablets.  I  then  seized  the  apex  of  one  pile  tumor 


312  ORIFIG1AL   SURGERY. 

in  a  pair  of  forceps,  and  with  curved  scissors  amputated  the 
hemorrhoid,  paying  no  attention  to  the  bleeding,  which  was 
profuse.  I  similarly  treated  the  cocainized  hemorrhoid  on  tne 
other  side  of  the  rectum.  On  removing  the  speculum  the 
bleeding  stopped  at  once  under  the  contraction  of  the  sphinc- 
ter. She  was  directed  to  apply  four  or  five  times  a  day  a 
cerate  made  of  hydrastis  and  hamamelis  and  aesculus,  to  wash 
out  the  rectum  with  a  cupful  of  weak  hamamelis  solution  after 
each  bowel  movement,  and  to  use  svapnia,  one-grain  supposi- 
tories, for  pain,  if  necessary,  the  first  day  or  two.  She  was 
obliged  to  keep  quiet  for  a  few  days,  although  not  confined 
to  the  bed.  After  two  weeks  the  surgical  treatment  was  re- 
peated in  other  parts  of  the  rectum,  and  this  course  followed 
out  until  all  hemorrhoids  and  papillae  were  removed.  The 
patient  reports  complete  relief  from  the  troublesome  symp- 
toms, and  says  she  feels  like  a  new  woman  ,and  cannot  thank 
me  enough  for  having  cured  her  without  hospital  operation. 
There  are  several  other  cases  with  a  history  of  similar  relief 
from  office  operations.  I  never  have  the  slightest  trouble  from 
the  cocaine  anesthesia,  as  I  give  strychnine  1-30  grain  by 
mouth  before  using  it.  The  free  bleeding  removes  danger 
of  toxic  effect.  Following  the  operation,  before  the  patient 
is  sent  home,  I  have  her  take  ^4  grain  morphine  by  mouth,  and 
require  her  to  rest  for  an  hour  or  so  at  the  office. 


CHAPTER  XXXIX. 


TREATMENT  OF  HEMORRHOIDS. 


C.   A.   PAULY,   M.   D. 


It  is  said  that  hemorrhoids  have  existed  as  long  as  the  hu- 
man race.  From  as  far  back  in  medical  history  as  we  are  able 
to  trace,  hemorrhoids  have  been  divided  into  two  varieties, 
external  and  internal.  Both  may  be  present  in  the  same  pa- 
tient at  the  same  time,  yet  they  can  always  be  distinguished 
from  each  other. 


ORIFICIAL   SURGERY.  313 

External  hemorrhoids  originate  in  a  subcutaneous  plexus 
of  vein  surrounding  the  anus;  they  are  below  the  sphincter 
muscles  and  are  not  connected  with  the  rectum  proper,  nor 
can  they  be  placed  above  the  external  sphincter  and  be  made 
to  remain  there.  Internal  hemorrhoids  originate  above  the 
sphincter  mu.«°]e,  and  they  never  appear  below  unless  induced 
by  straining,  which  may  be  due  to  constipation  and  other 
causes. 

The  external  sphincter  is  the  dividing  line  between  the 
two  varieties;  all  below  the  muscles  are  called  external,  all 
above  internal.  There  is  still  a  third  variety  (middle)  found 
on  the  dividing  line,  and  it  is  often  hard  to  determine  which 
variety  they  partake  of — external  or  internal. 

Very  few  people  have  reached  the  age  of  fifty  without 
having  suffered  with  external  piles,  and  possibly  internal, 
without  being  conscious  of  the  latter.  For  convenience  ex- 
ternal hemorrhoids  may  be  divided  into  three  forms:  The 
first  is  a  round  or  elongated  tumor  formed  by  the  extravasa- 
tion of  blood  in  the  subcutaneous  tissue  at  the  margin  of  the 
anus,  caused  by  the  rupture  of  a  dilated  vein.  The  tumor  ap- 
pears suddenly  and,  while  not  of  a  serious  nature,  is  very  an- 
noying. On  examination  the  physician  finds  a  hard  and  in- 
flamed tumor  filled  with  a  clot  of  blood. 

The  treatment  is  simple.  Make  an  application  of  a  4  per 
cent,  cocaine  solution,  wait  a  few  minutes  for  the  numbing  ef- 
fects, then  with  a  curved  bistoury  make  an  incision  through 
the  mucous  surface,  radiating  from  the  anus  as  a  center.  In- 
stead of  squeezing  the  tumor  to  remove  the  clot,  use  a  spud ; 
dress  the  wound  with  a  piece  of  carbolied  silk  or  iodoform 
gauze  placed  in  the  sac,  to  be  removed  the  next  day.  Hama- 
melis  or  calendula  cerate  can  be  applied  to  the  sac  until  the 
inflammation  subsides  and  the  soreness  disappears.  If  the  pa- 
tient will  not  submit  to  such  simple  surgical  measures,  put 
him  to  bed  and  have  cold  compresses  or  hot  poultices  applied 
to  the  parts,  and  wait  for  the  inflammation  to  subside,  if  not 
for  the  clot  to  be  absorbed. 

The  second  form  of  external  hemorrhoids  is  a  tumor  com- 
posed of  enlarged  or  varicose  veins  located  at  the  margin  of 


314  ORIFIC1AL   SURGERY. 

the  anus — the  tumors  may  be  multiple  and  surround  the  anus. 
This  variety  differs  from  the  first  by  not  being  circumscribed, 
not  coming  on  suddenly  and  not  being  formed  by  extravasa- 
tion of  blood. 

The  formation  is  gradual  and  the  patient  is  not  conscious 
of  the  tumors  until  their  increased  size  causes  pain  and  uneasi- 
ness during  the  act  of  defacation  and  for  some  time  after- 
wards. On  examination  the  anus  may  present  almost  a  nor- 
mal appearance.  If  the  patient  strains,  the  vessels  become 
turgent,  the  surface  about  the  anus  looks  purplish  and  the 
tumors  soon  present  themselves.  The  treatment  advocated  is 
carbolic  acid  injections,  electrolysis  and  the  cautery.  The 
two  latter  I  have  never  used,  and  with  carbolic  injections  I 
have  never  had  satisfactory  results  in  treating  tumors  having 
their  origin  outside  of  the  sphincter  muscles.  For  the  re- 
moval of  this  variety  I  prefer  rectal  dilatation  with  the  bi- 
valve speculum,  and  have  the  patient  use  the  rectal  plugs.  By 
their  use  the  circulation  through  the  veins  can  be  re-estab- 
lished and  in  time  the  tumors  will  disappear.  Furthermore 
the  use  of  the  plugs  will  overcome  constipation  which  is  often 
the  exciting  cause.  In  cases  requiring  surgical  work  in  or 
about  the  rectum,  necessitating  the  use  of  an  anesthetic,  these 
tumors  if  present  would  be  removed  at  the  same  sitting. 

The  third  variety  of  external  hemorrhoids  is  composed 
mostly  of  skin  and  connective  tissue.  It  may  be  the  remnants 
of  the  first  two  varieties.  It  has  lost  its  vascularity  and  pre- 
sents itself  in  the  shape  of  tabs  or  redundant  tissue.  One 
other  cause  might  lead  to  its  formation :  irritating  discharges 
from  disease  within  the  rectum.  This  form  or  variety  is  often 
very  troublesome;  the  tumors  become  inflamed,  the  mucous 
surface  cracked  or  fissured,  and  the  secretions  about  the  anus 
cause  pruritis;  the  latter  is  often  persistent,  keeping  the  pa- 
tient awake  most  of  the  night.  Treatment :  The  patient  will 
seldom  consult  the  physician  or  surgeon  when  the  tumors  are 
quiescent;  they  will  have  to  be  in  a  state  of  inflammation  or 
the  pruritis  is  severe  before  the  patient  will  ask  for  relief 
If  the  tumors  are  small  inject  a  few  drops  of  a  4  per  cent,  so- 
lution of  cocaine,  grasp  the  tumors  with  forceps  and  snip  off 


ORIFIC1AL   SURGERY.  315 

with  scissors.  The  slight  bleeding  that  follows  can  be  ar- 
rested with  styptic  cotton.  If  the  tumor  is  large  inject  co- 
caine at  one  or  more  points.  Snip  off  tumor  and  unite  edges 
of  wound  if  necessary  with  catgut.  The  slit  operation  is  pref- 
erable for  external  hemorrhoids  if  the  tumors  are  vascular. 
Should  the  patient  object  to  surgical  treatment,  local  applica- 
tions will  give  relief  and  correct  the  trouble  for  a  time.  For 
the  inflammation  that  might  be  induced  by  discharges  and  the 
rubbing  of  the  parts  to  relieve  the  itching,  application  of  cold 
water  and  the  use  of  different  ointments  such  as  belladonna 
and  opium  with  cosmoline,  campho-phenique  and  benzoated 
oxide  zinc  ointment  are  all  good  and  will  give  relief.  Rectal 
injections  of  hamamelis,  hydrastis  or  boracic  acid  will  be  bene- 
ficial. Applications  of  carbolic  acid  and  sweet  oil  (1-10)  to 
the  fissures  will  be  curative  and  quiet  the  itch.ng  tumors. 
For  internal  medication  graphites  and  salicylic  acid  should 
be  thought  of. 

Internal  hemorrhoids  are  varicosities  of  the  superior  and 
middle  hemorrhoidal  veins.  They  are  divided  into  two  varie- 
ties, capillary  and  venous ;  sometimes  a  third  is  given — arterial. 

Capillary  hemorrhoids  are  rare;  when  present  they  are 
found  high  up  in  the  rectum  or  down  near  the  sphincter;  each 
tumor  is  composed  of  the  terminal  branches  of  an  artery  and 
a  vein  joined  by  a  capillary.  The  tumors  resemble  a  strawberry 
in  appearance.  Their  surface  is  granular  and  covered  with  a 
very  thin  membrane.  The  delicate  structure  accounts  for  the 
free  hemorrhage  which  often  takes  place  from  the  slightest 
bruise  to  the  membrane.  The  leading  symptoms  of  a  capillary 
liemorrhoid  is  the  daily  hemorrhage  from  the  rectum.  On  ex- 
amination the  blood  can  be  seen  coming  from  the  strawberry- 
like  surface  of  the  tumors. 

Treatment.  A  thorough  application  of  nitric  acid  to  the 
surface  of  the  tumors  will  complete  a  cure.  Seldom  will  the 
second  application  be  needed.  The  venous  form  of  internal 
hemorrhoids  is  the  most  common.  It  is  void  of  the  capillary 
net  work  and  is  composed  of  a  mass  of  anastomosing  veins 
bound  together  by  connective  tissue.  The  veins  are  tortuous 
and  dilate  into  sacs  or  pouches.  Entering  the  base  of  these 


316  ORIPIC1AL   SURGERY. 

tumors,  one  or  more  arteries  can  be  found,  often  of  large  size. 
An  obstruction  to  the  portal  circulation  causes  the  tumors  to 
become  quite  large. 

Irritating  discharges  and  long  detention  of  fecal  matter 
in  the  rectum  cause  the  tumors  to  inflame  and  bleed  readily. 
Straining  at  stool  will  have  a  tendency  to  force  them  below 
the  sphincter  muscles.  If  the  exciting  cause  is  not  removed 
the  muscles  soon  become  relaxed  and  the  tumors  remain  out- 
side. Inflamed  piles  that  come  down  with  each  stool,  and 
are  constricted  by  the  sphincters,  are  very  painful.  The  tu- 
mors may  be  easily  reduced  at  first,  but  are  liable  to  fire  up 
from  different  causes,  such  as  over-indulgence  in  eating  and 
drinking,  and  become  so  swollen  that  the  patient  will  not 
be  able  to  replace  them.  When  called  to  a  case  of  this  kind 
the  patient  should  be  placed  on  the  face  with  pelvis  elevated. 
Apply  10  per  cent,  cocaine  ointment  to  the  piles;  wait  ten 
minutes  for  the  numbing  effect.  Then  try  to  reduce  the  tumors 
by  passing  a  well-anointed  finger  into  the  bowel  to  relax  the 
sphincters,  and  with  the  other  hand  gently  apply  pressure, 
trying  to  empty  the  tumors  of  their  superfluous  quantity  of 
blood  and  to  carry  them  above  the  grasp  of  the  sphincter  mus- 
cles. Failing  at  reduction,  apply  ice;  after  waiting  an  hour 
try  again  to  replace  the  tumors;  if  failure  is  the  result,  apply 
ice  for  relief.  If  ice  remains  on  the  piles  any  great  length  of 
time  it  will  cause  too  much  sloughing.  The  muscular  constric- 
tion of  the  piles  also  cause  sloughing.  The  application  of  a 
soothing  ointment,  followed  by  warm  poultices,  will  give  re- 
lief until  the  tumors  become  smaller  and  can  be  replaced. 

Treatment.  Before  recommending  a  surgical  operation 
for  the  removal  of  piles,  it  is  wise  to  consider  whether  the  case 
is  one  in  which  surgical  procedure  is  justifiable.  Internal 
hemorrhoids  are  symptoms  of  disease  in  a  number  of  the  vis- 
cera, such  as  stricture  of  the  rectum,  diseases  of  the  bladder, 
enlarged  prostates,  stricture  of  the  urethra  and  diseases  of  the 
uterus,  also  diseases  of  the  liver,  kidneys,  heart  and  lungs.  If 
it  is  possible  to  remove  the  exciting  cause  by  curing  these  dis- 
eases of  the  viscera  involved,  the  hemorrhoids  will  disappear. 
Medical  treatment  might  be  the  course  to  pursue — nux  vom- 


OEIFIC1AL,   SURGEKY.  317 

ica,  sulphur,  aloes,  collinsonia,  podophyllum,  aesculus  and 
hamamelis,  are  all  excellent  remedies,  and  should  be  thought 
of  in  diseases  of  the  different  viscera  with  hemorrhoidal 
symptoms. 

The  use  of  carbolic  acid  by  injection  for  the  cure  of  in- 
ternal hemorrhoids  is  greatly  condemned  by  the  profession  at 
large.  Notwithstanding  the  strong  objection  to  this  mode  of 
treatment,  many  cases  have  been  and  many  cases  can  be  cured 
with  this  treatment.  I  have  been  successful  with  the  carbolic 
injection  used  in  the  strength  of  1-10,  and  have  never  seen 
any  bad  results.  However  I  prefer  surgical  measures  for  the 
removal  of  piles,  but  many  patients  will  not  submit  to  the 
knife,  as  they  express  it.  If  the  general  health  of  the  patient 
is  good  and  his  sufferings  are  merely  local,  carbolic  injections 
may  be  all  that  is  needed  to  remove  the  hemorrhoids.  [A  50 
per  cent,  solution  of  carbolic  acid  in  olive  oil  is  better. — Ed.] 

Surgeons  of  the  older  school  have  devised  many  different 
operations  for  the  removal  of  hemorrhoids.  At  the  present 
day  they  recommend  but  two,  the  ligature  and  clamp  and 
cautery  operation ;  ocassionally  a  third,  the  Whitehead  or 
English  operation. 

The  ligature  is  crude  surgery  of  the  past.  The  clamp 
and  cautery  operation  has  little  to  recommend  it.  The  burn- 
ing causes  great  pain,  especially  if  the  skin  is  involved  in  the 
operation — secondary  hemorrhage  is  likely  to  occur.  Slough- 
ing takes  place,  healing  of  the  parts  is  slow  and  often  trou- 
blesome, contraction  is  common,  caused  by  the  formation  of 
scar  tissue,  which  is  non-elastic  and  liable  to  ulceration. 

In  conclusion  I  wish  to  make  the  following  statement :  For 
the  removal  of  internal  hemorrhoids  the  modified  clamp  and 
the  American  operation  if  performed  by  skillful  operators,  will 
give  better  and  more  satisfactory  results  than  either  the  clamp 
and  cautery  or  the  English  operations. 


318  ORIFIG1AL    SURGERY. 


CHAPTER  XL. 


THE  AMERICAN  OPERATION  IN  HEMORRHOIDS. 


EUG.   HUBBELL,    M.    D. 


The  American  operation  was  devised  by  Dr.  Pratt,  of 
Chicago,  whose  experience  in  rectal  surgery  has  been  greater, 
probably,  than  any  other  surgeon  in  America.  It  is  designed 
for  those  aggravated  cases  of  hemorrhoids  where  the  clamp, 
ligature,  or  Whitehead  operation  was  formerly  employed.  It 
is  to  my  mind  the  most  perfect  method  at  present  known  for 
the  radical  removal  of  the  pile-bearing  inch.  It  is  really  the 
only  surgical  operation  except  the  English  or  Whitehead,  for 
these  aggravated  cases.  It  differs  from  the  English  in  that 
the  operator  begins  at  the  upper  border  of  the  hemorrhoids 
and  dissects  downward  to  the  anal  verge,  instead  of  com- 
mencing at  the  anal  verge  and  working  up.  The  advantages 
are: 

1.  A  more  even  division  of  the  mucous  membrane  at  the 
upper  end,  which  is  difficult  to  obtain  in  the  English  operation. 

2.  Greater  rapidity  in  removing  hemorrhoidal  tissue. 

3.  Better  control  of  hemorrhage,  consequently  less  loss 
of  blood. 

The  clamp  or  ligature  operations  are  clumsy,  bungling, 
nerve-pinching,  tissue-crushing  means  that  often  produce  un- 
favorable results.  The  American  completely  eradicates  all 
tendency  to  hemorrhoids.  It  leaves  but  little,  if  any,  stiff,  un- 
wieldy cicatricial  tissue  in  the  grasp  of  the  sphincters,  hence 
incontinence  of  feces  seldom  if  ever  occurs.  A  brief  descrip- 
tion of  the  operation  may  not  be  out  of  place  here : 

The  bowels  should  be  thoroughly  emptied  and  cleansed 
prior  to  the  operation;  antiseptic  conditions  secured;  the  pa- 
tient anesthetized ;  on  operating  table  dorsal  position,  thighs 
strongly  flexed  on  the  abdomen  and  held  by  two  assistants;  the 
sphincters  thoroughly  dilated  by  Pratt 's  bivalve  speculum, 


ORIFIC'IAL   SURGERY.  319 

also  the  sigmoid,  which  is  then  packed.  The  hemorrhoids  are 
then  seized  by  T  forceps  and  completely  everted,  the  forceps 
being  held  by  assistants.  Commencing  at  the  upper  border  of 
hemorrhoidal  tissue  the  mucous  membrane  is  severed  trans- 
versely around  the  gut,  then  dissected  from  the  sphincters 
to  the  line  of  healthy  tissue  outside  where  it  is  severed.  The 
severed  end  of  mucous  membrane  should  now  be  drawn  down 
and  freed  from  connective  tissue  attachments  for  an  inch  or 
so  from  its  end,  to  let  it  more  freely  come  down  to  be  finally 
sutured  to  the  skin,  so  as  to  nicely  coapt  the  cut  surfaces  at 
the  outer  sphincter.  A  dry  dressing  is  best  applied;  this  cov- 
ered with  antiseptic  silk,  and  then  a  pledget  of  cotton,  and  all 
held  in  place  by  a  T  bandage.  The  patient  should  be  confined 
to  the  bed  for  two  weeks,  bowels  moved  by  enemata  after  third 
or  fourth  day ;  sometimes  a  little  smoothing  of  the  cicatricial 
rim  may  be  required.  I  wish  to  cite  a  few  cases  only : 

Case  1.  Mrs.  S.,  of  Faribult,  aet.  52,  has  suffered  from 
protruding  and  bleeding  piles  for  ten  years,  is  very  weak  and 
anemic.  The  American  operation  was  made  in  February,  1894, 
at  her  home.  The  amount  of  tissue  removed  was  very  great. 
She  made  an  uneventful  recovery,  regained  her  health,  and 
the  anus  is  today  as  smooth  and  perfect  as  if  there  never  had 
been  a  pile  there. 

Case  2.  Mr.  J.,  of  Owatonna,  aet.  33.  Man  of  fine  phy- 
sique ;  has  suffered  for  several  years  with  hemorrhoids.  Amer- 
ican operation  made  April  5th,  1894,  entirely  cured  him.  He 
was  up  and  at  his  office  the  tenth  day;  result  remains  perfect. 

Case  3.  Miss  R.,  of  Redfield,  S.  D.,  aet.  16.  Very  slen- 
der, weak,  despondent,  anemic  and  lifeless;  had  pockets, 
papillae,  erosions  of  bowel  with  hemorrhoids.  The  American 
completely  restored  the  rectal  pathology  and  started  her  out 
on  the  pathway  of  health. 

Case  4.  Mr.  D.,  of  this  city ;  occupation,  typesetter.  Had 
to  give  up  his  work  last  December  on  account  of  "piles."  I 
made  the  American  in  his  case  also,  but  his  recovery  was  not 
uneventful.  On  the  fourth  day  after  the  operation  he  arose 
and  emptied  the  bowels  of  large  hardened  feces  without  use 
of  anema.  Two  or  three  stitches  were  torn  out,  leaving  a  lit- 


320  ORIFIC1AL   SURGERY. 

tie  gap  which  did  not  granulate  well.  I  again  replaced  him 
upon  the  table  and  repaired  the  gap,  but  it  would  not  unite 
and  it  soon  began  to  slough.  I  again  anesthetized  him,  made 
a  sub-mucous  division  of  the  sphincters,  and  then  got  union. 
He  was  impationt  and  discouraged  at  one  time,  but  he  is  now 
happy,  cheerful  and  well,  and  at  his  old  place  at  work.  Had 
my  instructions  been  carried  out,  and  he  had  an  enema  to 
soften  the  stool,  it  would  have  saved  protracted  and  painful 
convalescence.  This  is  the  only  case  where  I  have  employed 
the  American  operation  in  the  removal  of  hemorrhoids  in  which 
I  have  had  any  unpleasant  features.  The  American  is  used  in 
many  other  rectal  complications  not  within  the  province  of 
this  paper  to  discuss. 

CHAPTER  XLI. 


THE  AMERICAN  OPERATION. 


E.   H.   PRATT,   M.   D. 


The  space  allotted  for  the  leading  article  for  the  present 
month  is  so  limited  that  it  will  be  impossible  to  do  justice  to 
any  subjct  requiring  extended  consideration.  We  will, 
therefore,  make  a  few  brief  suggestions  concerning  the  Ameri- 
can operation.  It  has  been  pretty  fairly  discussed  within  the 
last  few  months  in  various  medical  societies,  and  the  medical 
mind  is  at  the  present  time  considerably  divided  upon  the 
question  of  its  merits  and  demerits.  In  some  future  number 
of  the  Journal  we  shall  give  the  operation  another  and  more 
extended  consideration  than  we  can  do  in  the  present  article, 
so  as  to  do  what  we  can  toward  clearing  away  many  of  the 
vexed  questions  in  which  the  operation,  its  application  and 
results  at  the  present  time  seem  involved;  but  for  the  present 
we  shall  stop  with  just  a  few  practical  suggestions  concern- 
ing the  technique  of  the  operation. 

One  of  the  things  to  be  desired  in  the  operation  is  to  en- 
sure immediate  union  of  the  parts  so  as  to  avoid  retraction  of 


OKJFIC1AL  SURGERY.  321 

the  mucous  membrane,  cicatrization  of  the  surface,  and  the 
evil  consequences  which  are  liable  to  follow  such  a  result. 

There  are  five  things  which  have  a  tendency  to  prevent  im- 
mediate union: 

First,  lowering  the  position  of  the  internal  sphincter, 
bringing  its  lower  fibres  within  the  grasp  of  the  external 
sphincter  and  making  the  parts  clumsy  in  their  action. 

Second,  the  rupture  of  the  sphincters. 

Third,  malnutrition  of  the  mucous  membrane  at  the  time 
of  the  operation,  which  renders  impossible  the  rapid  repair  of 
any  wound  made  in  it. 

Fourth,  intermittent  spasms  of  the  sphincter  muscles, 
doing  violence  to  the  suturing,  and  causing  the  stitches  to  cut 
through  their  attachment  to  the  mucous  membrane. 

Fifth,  the  too  close  amputation  of  the  integument. 

These  difficulties  were  one  or  more  of  them  experienced  in 
the  earlier  operations,  and  have  had  much  to  do  with  the  un- 
satisfactory results  so  frequently  and  harshly  commented  up- 
on by  the  critics  of  the  operation.  Now  that  it  is  possible, 
however,  to  eliminate  every  objectionable  feature  in  the  op- 
eration, there  is  no  longer  necessity  for  unsatisfactory  results, 
and  in  the  course  of  time  it  will  win  its  way  into  much  more 
general  favor  than  it  at  present  enjoys. 

The  operation  is  so  perfectly  invaluable  in  such  a  large 
number  of  cases  that  those  who  have  learned  of  its  great 
power  in  the  cases  demanding  it  are  delighted  that  the  only 
really  objectionable  features  connected  with  the  operation 
have  been  overcome. 

That  the  loss  of  the  normal  sensations  of  the  anus  and 
of  the  control  of  the  bowels  to  even  the  slightest  degree  do  not 
necessarily  and  should  not  result  from  the  American  operation 
is  most  thoroughly  shown  to  any  fair-minded  person  who  will 
carefully  investigate  the  operation  and  its  results  in  a  consid- 
erable number  of  cases,  and  he  will  find  that  the  disastrous 
results  are  exceptional,  whereas  if  they  were  the  necessary 
consequences  of  the  operation  they  would  be  universal.  More 
than  that,  in  these  cases  the  unhappy  results  complained  of  are 
by  no  means  beyond  relief,  for  secondary  work,  properly  per- 


322  ORIFIC1AL    SURGERY. 

formed,  will  completely  remedy  them.  But  the  discussion  of 
the  subject  will  be  taken  up  again  when  we  come  to  a  more 
thorough  consideration  of  the  operation  in  all  its  bearings. 

For  the  benefit  of  those  who  may  not  yet  have  fully  solved 
the  problems  of  the  operation,  we  will  briefly  consider  the 
points  mentioned  in  the  order  of  their  enumeration. 

First,  lowering  the  position  of  the  internal  sphincter, 
thus  bringing  its  lower  fibres  within  the  grasp  of  the  external 
sphincter,  and  making  the  parts  clumsy  in  their  action. 

The  internal  sphincter  muscle  clings  to  the  mucous  mem- 
brane, which  it  encloses  more  or  less  closely,  being  loosely 
held  in  contact  with  it  by  delicate  areolar  tissue.  After  the 
rim  of  mucous  membrane  lining  the  last  inch  of  the  rectum 
has  been  taken  away  and  the  severed  margins  of  the  mucous 
membrane  are  united  to  the  severed  margins  of  the  skin,  the 
mucous  membrane,  of  course,  is  pulled  down  to  a  more  or 
less  extent  according  to  the  redundancy  of  the  tissues.  As  the 
mucous  membrane  lining  the  rectum  is  always  sufficiently  re- 
dundant to  render  the  operation  possible  without  any  consid- 
erable degree  of  tension  upon  it,  no  harm  results  to  the  mem- 
brane itself;  but  as  it  is  brought  down  from  above  it  brings 
with  it  the  internal  sphincter  muscle,  and  before  it  is  fastened 
to  the  integument  this  muscle  should  be  carefully  loosened 
from  the  mucous  membrane  around  its  entire  circumference  by 
the  aid  of  a  pair  of  sharp-pointed  scissors  or  a  spud.  In  seiz- 
ing the  severed  margin  of  the  mucous  membrane  with  T-for- 
ceps,  for  the  purpose  of  bringing  it  into  position  for  suturing, 
the  forceps  impinge  also  upon  the  severed  extremities  of  the 
longitudinal  fibres  of  the  gut.  As  the  fibres  are  somewhat 
pale  it  is  not  easy  to  distinguish  between  them  and  the  under 
surface  of  the  mucous  membrane  except  for  the  tension  which 
they  exercise  when  traction  is  made  upon  the  forceps.  It  does 
no  harm,  therefore,  and  an  operator  is  less  liable  to  do  violence 
to  the  mucous  membrane  if,  instead  of  trying  to  pull  the  longi- 
tudinal fibres  loose  from  the  mucous  membrane,  he  takes  pains 
to  sever  them  close  to  the  attachment  of  the  forceps.  As  soon 
as  the  longitudinal  fibres  of  the  rectum  are  thus  severed  close 
to  the  attachment  of  the  forceps  and  completely  around  the 


ORIFIC'IAL    SURGERY.  323 

circumference  of  the  gut,  the  loose  areolar  tissue  which  sep- 
arates the  mucous  membrane  from  the  muscular  coats  can  be 
easily  loosened  with  the  spud  or  a  pair  of  closed  scissors,  and 
the  sphincter  muscle,  which  is  always  within  sight,  can  thus 
be  very  easily  pushed  back  from  the  mucous  membrane  until 
as  much  mucous  membrane  has  been  bared  of  the  muscle  as 
was  amputated  during  the  operation.  When  this  is  care- 
fully accomplished  and  the  mucous  membrane  is  stitched  to 
the  integument  the  internal  sphincter  will  occupy  its  normal 
position  and  thus  escape  being  enclosed  in  the  grasp  of  the 
external  sphincter.  The  action  of  the  muscle  is  not  in  the 
slightest  interfered  with,  and  no  harm  ever  comes  from  thus 
loosening  it  and  leaving  it  in  its  normal  position  while  at  the 
same  time  the  mucous  membrane  is  slid  down  to  meet  the  in- 
tegument. 

Second,  the  rupture  of  the  sphincters. 

Some  sphincter  muscles  are  exceedingly  friable,  and  if  di- 
latation, which  is  always  to  be  practiced  before  the  operation 
is  performed,  is  in  the  slightest  degree  violent,  or  if  it  be  rap- 
idly accomplished,  some  fibres  of  the  external  sphincter  are 
very  liable  to  be  ruptured.  The  rupture  invariably  takes 
place  at  the  posterior  commissure.  After  the  strip  of  mucous 
membrane  has  been  removed  and  the  longitudinal  fibres  of 
the  rectum  are  severed,  while  the  T-forceps  are  still  gripping 
the  lower  border  of  the  severed  mucous  membrane,  by  their 
aid  the  rectum  can  be  brought  down  and  the  parts  everted, 
so  as  to  bring  the  external  sphincter  thoroughly  into  view.  If 
it  is  found  to  be  even  partially  ruptured  it  is  better  to  coapt 
its  margins  by  one  or  two  catgut  ligatures,  for  although  it 
might  heal  without  this  protection,  nevertheless  the  suturing 
ensures  it. 

Third,  malnutrition  of  the  mucous  membrane  at  the  time 
of  the  operation,  which  renders  impossible  the  rapid  repair  of 
any  wound  made  in  it. 

After  the  patient  is  under  an  anesthetic  and  the  parts 
thoroughly  cleansed  for  operation,  during  the  process  of  di- 
latation it  is  an  easy  matter  to  observe  the  degree  of  tonicity 
possessed  by  the  mucous  membrane.  If  the  tissues  are  so 


324  ORIFIG1AL   SURGERY. 

softened  that  moderate  dilatation  produces  more  or  less  edema 
and  causes  small  hematoceles,  if  it  is  so  friable  that  it  bleeds 
and  lacerates  under  manipulation,  then  it  is  morally  certain 
that  it  does  not  possess  sufficient  integrity  to  hold  the  neces- 
sary stitching.  Upon  the  slightest  provocation,  as  vomiting, 
coughing,  an  early  passage  of  the  bowels,  or  spasmodic  action 
of  the  sphincters,  the  stitches  will  cut  through  the  mucous 
membrane  and  retraction  will  take  place.  Such  cases  should 
not  receive  the  American  operation,  regardless  of  the  appar- 
ent need  for  it,  but  measures  should  be  inaugurated  to  restore 
to  the  mucous  membrane  its  tonicity,  which  can  be  done  in 
from  two  weeks  to  three  months,  according  to  the  reactive 
powers  of  the  patient,  at  the  end  of  which  time  the  operation 
can  be  successfully  performed.  The  measures  by  which  the 
tonicity  of  the  membrane  can  be  restored  are  systematic  di- 
latation, the  application  of  heat  and  cold  both  over  the  pu- 
denda and  buttocks  and  within  the  rectum,  and  local  feeding, 
the  latter  being  best  accomplished  by  the  daily  use  of  small 
injections  of  bovinine,  which  can  be  diluted  in  cases  too  irri- 
table to  endure  its  application  in  full  strength.  The  daily 
application  of  water  as  hot  as  can  be  borne,  to  be  immediately 
followed  by  ice  water,  over  the  pudenda  and  base  of  the  body, 
is  an  exceedingly  effective  measure  in  re-establishing  the  cap- 
illary circulation  throughout  the  pelvic  organs  and  thus  re- 
storing their  integrity.  Dilatation  can  be  accomplished  either 
by  the  rectal  speculum  or,  what  is  better,  by  some  form  of 
rectal  plugs — "Weirick's,  Young's,  Linn's,  Pratt 's,  or  any  other 
of  the  numerous  varieties  in  which  the  market  abounds.  These 
can  be  used  at  the  discretion  of  the  surgeon  in  charge,  and  ac- 
cording to  the  instructions  given  for  their  use  already  laid 
down  in  a  previous  number  of  the  Journal.  Electricity  should 
also  be  enumerated  in  the  list  of  tonic  measures.  Where  the 
mucous  membrane  lining  the  rectum  is  in  a  condition  of  malnu- 
trition, the  weakened  condition  is  liable  to  extend  the  entire 
length  of  the  colon,  so  that  in  employing  electricity  it  is  well 
to  insert  the  rectal  electrode  not  only  into  the  rectum  itself, 
but  well  into  the  sigmoid,  and  by  means  of  a  fountain  syringe 
flood  the  large  intestine  with  water  strongly  impregnated  with 


ORmCIAL   SURGERY.  325 

salt.  In  this  way  the  electrical  current  can  do  good  service  not 
only  for  the  rectum  itself,  but  along  the  entire  length  of  the 
large  intestine.  Both  the  galvanic  and  the  faradic  currents 
will  be  found  of  service,  and  may  be  employed  at  the  same  sit- 
ting. After  the  rectal  electrode  is  removed  it  is  well  to  intro- 
duce the  sigmoid  speculum,  and  after  a  succussion  of  the  sig- 
moid,  while  the  instrument  is  being  held  open  by  the  operator 
it  can  be  expelled  by  the  patient,  thus  not  only  clearing  the 
sigmoid  of  any  fecal  matter  that  may  be  present  but  also  dilat- 
ing the  anus  at  the  same  time.  These  treatments  may  be  given 
daily,  or  less  often,  at  the  discretion  of  the  surgeon.  It  is  good 
practice  to  employ  electricity  in  this  manner  and  follow  its  ap- 
plication with  the  use  of  hot  and  cold  water  as  just  mentioned, 
all  at  the  same  sitting.  Of  course  in  many  cases  the  sexual 
system,  regardless  of  sex  will  demand  more  or  less  attention  ac- 
cording to  its  condition,  as  in  cases  where  the  mucous  mem- 
brane of  the  rectum  is  atrophied  there  will  be  a  corresponding 
condition  of  weakness  of  the  sexual  organs,  and  this  must  be 
corrected  in  order  to  secure  the  results  desired  from  the  treat- 
ment of  the  rectum.  The  means  for  re-establishing  sexual  tone 
have  already  been  considered  in  a  previous  number  of  the 
Journal,  and  consequently  need  not  be  repeated  in  the  present 
connection. 

Fourth,  intermittent  spasms  of  the  sphincter  muscles,  do- 
ing violence  to  the  suturing  and  causing  the  stitches  to  cut 
through  their  attachment  to  the  mucous  membrane. 

This  has  been  one  of  the  serious  problems  of  the  operation, 
and  until  recently  has  not  been  satisfactorily  solved,  the  hy- 
podermic use  of  morphine  being  almost  the  only  means  at  our 
command  for  controlling  them,  and  even  then  the  exhibition 
of  retching  or  coughing  or  sneezing  or  laughing  was  to  be 
dreaded.  There  is  now  a  very  satisfactory  solution  of  this 
problem,  and  singular  as  it  may  appear,  it  is  nothing  more 
nor  less  than  the  employment  of  a  subcutaneous  stitching  of 
the  skin  side  of  the  wound.  The  continuous  stitch  may  pierce 
the  mucous  membrane  as  formerly  advised,  but  instead  of 
piercing  the  skin  it  is  made  to  transfix  only  the  cutis  vera, 


326  ORIFIG1AL    SURGERY. 

never  entering  the  skin  far  enough  to  impinge  upon  its  papil- 
lary layer.  The  needle  may  be  either  entered  perpendicularly 
or  longitudinally  to  the  wound,  the  only  point  being  to  confine 
it  to  the  deeper  parts  of  the  cutis  vera.  In  this  manner  a  beau- 
tiful coaptation  of  the  very  margins  of  the  skin  and  the  margins 
of  the  mucous  membrane  is  secured ;  at  the  same  time  it  avoids 
almost  entirely  the  subsequent  pain  and  soreness  resulting 
from  the  operation  as  previously  performed.  The  patients 
consequently  require  less  morphine,  a  large  number  indeed  not 
requiring  any,  and  the  spasmodic  action  of  the  external  sphinc- 
ter seems  to  be  almost  completely  avoided.  As  a  consequence 
union  by  first  intention  is  almost  uniformly  secured,  and  there 
is  also  no  subsequent  stricture  to  contend  with. 

Fifth,  the  too  close  amputation  of  the  integument. 

When  the  operation  has  proceeded  so  far  that  the  mucous 
lining  of  the  last  inch  has  been  amputated,  peeled  downward, 
and  is  held  dangling  below  the  anus  by  the  forceps  which  are 
still  attached,  care  being  taken  not  to  exercise  more  traction 
than  is  necessary  to  merely  straighten  the  mucous  membrane 
to  be  removed,  a  groove  will  be  observed  completely  surround- 
ing the  anus,  which  marks  the  angle  at  which  the  perpendicu- 
lar tissues  are  continuous  with  the  horizontal  ones  covering 
the  buttocks.  In  the  earlier  history  of  the  operation  it  was 
advised  to  amputate  the  integument  right  at  this  angle.  But 
since  it  has  been  found  advisable  to  sever  the  longitudinal 
fibres  of  the  gut  and  peel  back  the  internal  sphincter,  thus 
more  freely  liberating  the  mucous  membrane,  it  has  been  found 
that  a  corresponding  allowance  must  be  made  in  the  amount 
of  the  integument  amputated.  There  is  less  tendency  to  re- 
traction of  the  mucous  membrane,  and  consequently  the  skin 
will  not  be  drawn  so  far  inward  as  in  the  operation  earlier 
performed.  For  this  reason,  instead  of  making  the  amputa- 
tion of  the  integument  at  the  bottom  of  the  groove  just  men- 
tioned, it  is  better  to  remove  less  of  the  integument.  The  am- 
putation may  be  made  along  the  line  a  quarter  of  an  inch  from 
the  bottom  of  the  groove,  of  course  on  the  side  to  which  the 
mucous  membrane  is  attached.  This  will  avoid  all  danger  of 
ectropion  of  the  mucous  membrane.  Cases  of  ectropion  can  be 


ORIFIGIAL   SURGERY.  327 

remedied  by  a  subsequent  operation,  but  it  is  much  better  not 
to  produce  them. 

In  the  points  mentioned  the  American  operation  has  been 
very  materially  improved,  and  it  is  possible  that  still  further 
improvement  may  be  instituted,  so  that,  when  performed  with 
proper  care  and  precaution  and  used  as  a  last  resort  for  the 
cure  of  cases  for  which  milder  measures  have  proven  them- 
selves inadequate  after  thorough  trial,  it  need  never  be  con- 
demned, nor  even  dreaded.  The  operation  has  now  been  per- 
formed with  such  pronounced  success  in  so  many  hundreds  of 
cases,  in  which  the  gratitude  of  the  patients  for  their  restora- 
tion to  health  has  been  so  warmly  and  repeatedly  expressed, 
that  the  establishment  of  the  operation  in  its  present  degree  of 
perfection  will  have  to  be  chronicled  as  one  of  the  greatest 
surgical  accomplishments  of  the  age. 

The  orificial  philosophy  does  not  depend  either  for  its 
universal  establishment,  or  for  its  permanence  of  recognition, 
upon  any  particular  method  either  of  operation  or  of  treat- 
ment, and  the  success  or  failure  of  the  American  operation,  or 
any  other  operation  employed  by  the  present  practitioners  of 
orificial  surgery,  cannot  in  the  slightest  influence  the  sound- 
ness of  orificial  teachings,  for  these  are  based  upon  the  well- 
known  facts  of  anatomy  and  physiology,  which  must  always 
remain  until  the  plans  of  creation  undergo  material  change. 
The  favor,  therefore,  with  which  the  American  operation  is 
ultimately  received  by  the  medical  fraternity  is  a  matter  of 
comparative  indifference  to  the  true  orificialist.  He  will  be 
very  glad,  indeed,  to  abandon  the  operation,  as  indeed  he  will 
hysterectomy,  laceration  of  the  cervix,  perinea!  section,  or  any 
other  formidable  surgical  procedure,  whenever  simpler  means 
will  accomplish  his  purpose.  The  early  removal  of  pockets  and 
papillae,  and  a  proper  attention  to  the  foreskin,  frenum  and 
meatus  of  the  male,  and  hood  of  the  clitoris,  meatus,  vulva, 
cervix  and  positions  of  the  uterus  of  the  female,  will  undoubt- 
edly in  the  course  of  time  dispense  with  all  forms  of  major 
work  in  the  pelvic  organs.  But  until  pelvic  hygiene  is  begun 
in  infancy  and  continued  throughout  all  earth  life,  major  op- 
erations upon  the  pelvic  organs  will  be  repeatedly  called  for; 


328  ORtFIClAL   SURGES?. 

and  among  them  will  be  the  American  operation,  for  although 
it  will  always  occupy  the  position  of  a  last  resort,  patients  will 
be  abundant  who  have  so  neglected  themselves  before  applying 
for  relief  that  nothing  but  a  last  resort  measure  will  be  ade- 
quate to  the  case.  The  American  operation  has  unquestionably 
come  to  stay,  and  the  very  best  that  we  can  do  is  to  be  as  con- 
servative and  as  skillful  as  possible  in  our  employment  of  it, 
and  be  very  sure  that  we  make  use  of  it  only  as  a  last  resort, 
either  as  a  local  measure  or  as  a  means  of  re-establishing  gen- 
eral nutrition,  for  this  is  all  it  was  ever  invented  for  or  rec- 
ommended for,  and  all  that  it  should  ever  be  employed  for. 
So  long  as  through  neglect  or  other  causes  last  resorts  are 
sometimes  needed,  we  have  every  reason  to  be  grateful  for  the 
American  operation,  as  for  all  other  extreme  measures  which 
are  our  sole  reliance  in  times  of  great  need. 


CHAPTER  XLII. 


RECTAL  DISEASES— FISTULA. 


T.   E.   COSTAIN.   M.   D. 

In  the  whole  range  of  surgical  pathology  no  other  disease 
is  so  prevalent  or  succumbs  so  readily  to  judicious  treatment. 
Many  of  these  diseases  are  due  to  irregularities  of  habit,  mode 
of  living,  and  lack  of  proper  care  of  the  part.  Many  may  be 
mistaken  for  prostatic  condition, — or  cystitis.  In  order  to  dif- 
ferentiate a  careful  examination,  both  visual  and  digital,  is 
necessary. 

Anatomically  considered,  the  rectum  is  that  part  of  the 
alimentary  canal  from  the  sigmoid  to  the  anus.  Considered 
nervously  it  is  that  from  the  left  one-half  of  the  transverse 
colon  to  the  anus,  because  the  inferior  mesenteric  plexus  of 
nerves  supplies  all  of  that  part  alike,  and  as  the  fecal  mass  is 
often  lodged  in  the  left  one-half  of  the  transverse  colon  and 
sigmoid,  it  makes  these  two  so  closely  associated  with  the 
rectum  as  to  almost  become  a  part  of  it.  You  will  remember 


ORIFIC1AL    SURGERY.  329 

that  the  rectum  has  three  coats;  one,  the  peritoneal,  only  cov- 
ering a  portion  of  it,  the  mucous  and  muscular  coats  continu- 
ing to  the  anus.  The  arterial  supply  is  the  superior  hemor- 
rhoidal  from  mesenteric,  inferior  hemorrhoidal  from  internal 
pubic.  Veins  correspond  in  names  to  the  arteries.  Nerve  sup- 
ply is  from  sacral  plexus,  and  sympathetic  from  mesenteric 
and  hypogastric  plexuses. 

Before  proceeding  further  I  want  to  call  your  attention 
to  the  intimate  relation  existing  between  these  nerves  and  the 
genito-urinary  tract,  branches  from  the  same  nerve  supplying 
both.  And  often  the  rectum  may  be  at  fault,  with  the  pain  re- 
flexed  to  some  part  of  the  genito-urinary  tract.  Guarding 
the  anus  we  find  two  sphincter  muscles,  the  external  and  the 
internal  sphincters.  Reinforcing  these  two  muscles  we  find 
the  levator  ani,  the  action  of  which  is  to  compress  the  sides  of 
the  rectum  and  neck  of  the  bladder,  and  in  the  act  of  defeca- 
tion when  the  sphincter  contracts  to  open  the  anus.  It  also 
has  a  slight  sphincter  action  and  aids  contraction  of  the  anus 
when  the  sphincter  is  destroyed. 

The  external  sphincter  surrounds  the  outer  margin  of  the 
anus,  and  is  found  surrounding  the  lower  portion  of  the  gut, 
but  not  intimately  connected  with  it.  The  internal  sphincter, 
on  the  other  hand,  lies  immediately  around  the  gut  and  is  in- 
timately and  closely  associated  with  it. 

We  will  now  consider  and  classify  diseases  peculiar  to  the 
rectum,  remembering  at  the  same  time  that  from  an  orificial 
standpoint  local  pathological  conditions  not  only  cause  local 
discomfort  but  affect  the  general  nutrition  of  the  body. 

We  will  now  consider  rectal  diseases  from  a  local  stand- 
point. Before  taking  up  the  consideration  of  individual  rectal 
disorders  we  will  talk  in  a  general  way  of  the  subjective  symp- 
toms which  will  call  the  patient's  attention  to  the  part,  and 
later  objective  symptoms,  which  we  can  see  by  examination. 

As  I  have  already  told  you,  the  fact  that  you  cannot  glean 
from  the  patient  anything  which  would  suggest  any  local  dis- 
order is  no  reason  why  you  should  not  inspect  and  examine 
this  part  for  yourself.  Often  the  irritation  is  carried  by  me- 
tastasis to  remote  parts  of  the  body  and  does  far  more  dam- 


330  ORIFICIAL    SURGERY. 

age  to  the  patient's  health  than  if  extensive  local  pathology 
existed.  Pain  will  exist  with  fistula,  fissure,  acute  hemor- 
rhoids, ulceration,  and  morbid  growths.  In  fissure  the  pain  is 
out  of  proportion  to  the  local  lesion,  usually  coming  on  during 
the  act  of  defacation  and  lasting  afterward  for  some  time.  It 
is  of  a  hot,  smarting  character,  and  radiates  toward  the  coc- 
cyx. Pain  due  to  fistula  is  more  often  found  in  the  acute  stage 
than  later,  when  it  becomes  chronic.  This  pain  takes  the  char- 
acter of  inflammatory  pain,  which  is  found  in  an  abscess  any- 
where. In  acute  hemorrhoids  the  pain  is  in  proportion  to  the 
size  and  number  of  the  tumors  and  the  amount  of  the  sur- 
rounding inflammation.  In  ulceration,  unless  it  lies  directly  in 
the  grip  of  the  sphincter,  the  pain  is  only  of  a  minimum 
amount.  In  malignant  diseases  the  pain  depends  largely  upon 
the  extent  and  location  of  the  disease,  being  much  greater  if 
situated  between  the  sphincter  muscles.  If  the  disease  be  high 
up,  even  though  extensive,  very  little  or  no  pain  would  be 
felt.  By  inspection  you  will  know  prolapsus  retg,  external 
hemorrhoids,  polypi,  and  villous  growths.  Hemorrhage  maj 
be  seen  and  may  be  a  symptom  of  bleeding  hemorrhoids,  pro- 
lapsus, fissures,  ulcers,  strictures,  malignant  disease,  polypi, 
wounds,  and  the  presence  of  foreign  bodies  in  the  rectum. 
Blood  may  indicate  acute  inflammations  and  ulcerations  of  the 
intestines  or  stomach.  By  digital  examination  or  by  exposing 
the  field  with  a  speculum — the  Pratt  speculum  being  the  best 
for  this  purpose — you  can  note  all  the  foregoing  and  can  ex- 
amine for  pockets  and  papilla?  and  middle  and  internal  hem- 
orrhoids, strictures,  ulceration,  complete  fistula,  pus,  etc.  The 
patient's  own  diagnosis  should  never  be  taken,  and  even  the 
family  physician's  diagnosis  should  be  supplemented  by  an  ex- 
amination by  yourself.  An  enema  should  be  given  when  pos- 
sible before  examination,  as  a  fecal  mass  may  obstruct  the  up- 
per rectum  from  view  on  the  introduction  of  the  speculum. 

Position. — For  an  ordinary  digital  examination  the  semi- 
prone  or  Sims  position  is  most  convenient,  but  the  lithotomy 
position  will  be  best  if  you  wish  to  explore  the  field  higher  up 
in  the  rectum.  Very  often  it  will  be  difficult  to  make  more 
than  a  digital  examination  without  an  anesthetic.  The  amount 


ORIFIC1AL    SURGERY.  331 

of  pain  caused  by  the  use  of  the  speculum  will  not  be  well 
borne  in  sensitive  cases.  As  a  rule  in  these  cases  the  digital 
examination  will  determine  whether  an  -anesthetic  will  be  ne- 
cessary, and  a  further  examination  can  be  made  under  anes- 
thesia if  further  explorations  should  become  necessary.  If  the 
digital  examination  be  carefully  made  it  will  give  you  much 
valuable  information ;  first,  note  the  strength  of  the  sphincter 
muscle.  A  tight  sphincter  denotes  irritation  in  the  last  inch 
of  the  rectum — pockets,  papilla1,  fissures,  etc.,  and  an  inordi- 
nate amount  of  nerve  waste.  A  weak  sphincter  denotes  deep- 
er situated  trouble;  it  means  a  weakened  system,  a  weakened 
sympathetic  nerve,  or,  worse  still,  a  malignant  disease  of  the 
rectum.  By  sweeping  the  finger  around  the  rectal  wall  pa- 
pillae, hemorrhoids,  fissures,  strictures,  etc.,  and  in  the  male 
prostatic  conditions  may  be  found,  and  in  the  female  the  uterus 
may  be  found  pressing  on  the  rectal  wall  and  its  position  may 
be  readily  noted. 

The  examination  having  been  made,  a  diagnosis  of  the 
case  determined  upon,  we  now  come  to  the  proper  methods  of 
handling  the  various  diseases  liable  to  be  found  in  that  part. 
We  will  first  take  up  the  subject  of  the  fistula  in  ano. 

There  are  two  classes  of  these  cases ;  those  who  suffer  only 
a  local  discomfort,  and  those  who  suffer  with  profound  reflex 
disturbance  in  addition  to  the  local  disturbance.  The  pudic 
nerve,  which  is  a  branch  of  the  cerebro-spinal  system,  is  re- 
sponsible in  itself  for  many  nervous  reflexes;  but  when  we 
consider  its  action  in  the  sacral  region  with  the  sympathetic 
system,  we  have  a  wire  to  the  central  office  of  both  systems, 
over  which  the  messages  from  a  broad  surface  of  decomposed 
tissue  are  constant.  The  superiority  of  the  train  of  reflexes 
depends  somewhat  upon  the  power  of  each  nerve  to  resist 
them.  In  cases  where  the  disturbance  is  local  we  find  the  pa- 
tient in  apparent  good  health.  These  cases,  however,  have  a 
very  much  weakened,  sympathetic  nervous  system,  and  in  con- 
sequence its  normal  function  is  greatly  disturbed.  In  other 
cases  we  find  not  only  disturbed  function  but  a  weakened  and 
emaciated  body  and  a  train  of  nervous  disturbances,  which 
at  first  glance  seems  almost  beyond  our  aid. 


332  ORIFIG1AL   SURGERY. 

Irritation  from  the  terminal  nerves  of  the  rectum  affects 
not  only  the  adjacent  organs,  but  the  liver,  stomach,  heart,  in- 
testines, and  the  equilibrity  of  nerve  force.  The  heart  is  af- 
fected directly  by  the  lateral  chain  of  sympathy  directly  to 
the  cerebral  ganglia  and  the  intermingling  of  the  fibers  from 
the  solar  plexus  and  pneumogastric  nerve.  The  hypogastric 
plexus  conveys  impressions  to  the  stomach  and  intestines 
through  the  gastric  plexus  and  its  branches  to  Auerbach's  and 
Meissner's  plexuses,  the  whole  being  a  branch  of  the  great 
solar  plexus. 

This  same  action  occurs  in  other  organs  mentioned  and 
causes  a  variety  of  nerve  symptoms  which  would  reach  almost 
all  the  nervous  phenomena  known  to  be  due  to  the  constant  ir- 
ritation of  any  of  the  lower  openings. 

A  fistula  in  ano  may  be  defined  as  a  non-granulating  sinus 
with  two  openings,  one  upon  the  surface  and  the  other  within 
the  rectum.  The  inner  opening  usually  lies  between  the 
sphincter  muscles. 

Fistula  in  ano  is  the  result  of  an  abscess  either  external 
or  internal  to  the  sphincter  muscles,  and  of  many  recognized 
forms  among  them  are  the  complete,  blind  external,  blind  in- 
ternal, horseshoe,  recto-vaginal,  recto-vesical.  These  forms 
may  again  be  divided  into  fistula  due  to  pyogenic  cocci  and 
those  of  the  tubercular  type. 

We  will  consider  fistulas  in  general  from  the  latter  stand- 
point. The  first  thing  to  be  done  with  a  case  of  this  kind  is 
to  get  a  diagnosis  of  whether  the  trouble  is  due  to  tubercular 
bacilli  or  pyogenic  cocci,  such  as  staphyloeoccus  or  streptococ- 
cus, or  bacillus  foetidus,  or  to  either  of  them  singly  and  com- 
bined with  tubercular  bacilli.  This  can  be  accomplished  by 
making  a  culture  of  the  pus  immediately  after  or  at  the  time 
you  make  the  examination.  This  culture  should  then  be  sub- 
jected to  the  proper  tests  and  a  slide  for  the  microscopicaf  ex- 
amination made.  After  you  have  become  convinced  that  tu- 
bercular bacilli  are  or  are  not  present,  you  know  whether  the 
case  is  going  to  be  an  extremely  difficult  and  tedious  one  or 
one  in  which  you  have  hope  for  an  early  closing  up  of  the 


ORIFIC1AL   SURGERY.  333 

entire  trouble.  In  my  experience  the  treatment  of  the  two  is 
radically  different. 

In  the  case  of  fistula  of  the  pyogenic  origin  alone,  I  would 
recommend,  before  operating,  that  all  proper  care  should  be 
taken  to  cleanse  the  wound  as  much  as  possible.  Irrigate  with 
an  antiseptic  solution  for  a  day  or  two,  if  necessary  putting 
on  the  antiseptic  wet  dressing  continuously  for  twenty-four  or 
forty-eight  hours,  and  make  the  wound  as  near  antiseptic  as 
is  possible  under  the  circumstances.  By  observing  thoroughly 
aseptic  and  antiseptic  technique  during  the  operation  we  can 
hope  for  a  wound  which  will  heal  readily  after  the  following 
method : 

If  the  fistula  is  a  single,  complete  one,  with  the  inner 
opening  between  the  sphincters,  lay  open  the  tract  up  to  the 
margin  of  the  sphincter  muscle.  Now  feel  for  the  hard  cord 
running  into  the  wall  of  the  bowel,  and  dissect  from  the  up- 
per point  toward  the  bowel;  grasp  these  loose  ends  in  a  pair 
of  plug  or  T  forceps,  and  dissect  the  cord  out  clean.  The  mu- 
cous membrane  of  the  bowel  can  be  brought  together  by  some 
stitches,  closing  the  internal  opening;  deep  sutures  can  then 
be  passed,  if  necessary,  through  the  mucous  membrane,  but 
preferably  from  the  outside,  approximating  the  wound.  These 
stitches  can  then  be  continued  down  through  the  wound,  af- 
ter dissecting  out  the  bottom  of  the  open  wound  most  thor- 
oughly, and  the  parts  stitched  together  completely.  In  case 
healing  fails  to  take  place  by  first  intention,  the  wound  can 
be  treated  very  readily,  or  such  part  of  it  as  does  not  heal  by 
subsequent  cleaning  up  of  the  wound,  or  by  stitching  it  if 
the  wound  is  already  clean. 

In  the  case,  however,  of  a  tubercular  fistula,  there  is  no 
use  bringing  it  together  at  all,  because  it  will  not  heal.  This 
should  be  treated  as  an  open  wound,  and  should  be  packed 
with  iodoform  or  nosophen  gauze,  and  this  dressing  changed 
and  the  wound  cleaned  night  and  morning  and  after  each  bow- 
el movement,  the  first  bowel  movement  taking  place  about  the 
fourth  day.  After  a  time  this  dressing  will  become  ineffica- 
cious, and  it  will  tax  your  patients  and  knowledge  of  drugs  of 
every  variety  to  get  the  wound  active  at  all.  Cauterization, 


334  ORIFIG1AL    SURGERY. 

either  by  carbolic  acid,  nitrate  of  silver,  or  the  various  other 
agents  known  to  be  good,  or  by  electricity,  using  the  positive 
pole,  will  aid  you  for  a  time;  jute  saturated  with  balsam  of 
Peru,  packed  into  the  wound,  will  stimulate  granulations,  and 
is  of  itself  a  thorough  antiseptic ;  in  fact,  I  have  seen  it  clean 
up  wounds  when  nothing  else  seemed  to  be  of  any  service. 
flodum-Miller  will  be  found  very  effective. — Ed.]  If  the 
wound  should  become  clean  and  granulations  fresh,  an  effort 
should  be  made  to  bring  the  edges  together  by  putting  in  either 
a  button  or  quill  suture.  The  suture  of  any  material  tied  will 
cut  through  the  tissues,  in  spite  of  the  most  persistent  care,  as 
the  tissues  around  a  tubercular  fistula  become  softened  and  lose 
their  integrity  to  a  great  extent.  You  may  be  able  to  gain 
quite  a  little  by  this  suture,  sometimes  healing  it  entirely,  but 
in  any  event  it  is  a  long  and  tedious  process.  Success  is  yours 
if  you  will  continue  your  efforts,  as  I  have  never  known  them 
not  to  be  healed  in  the  end,  with  possibly  a  single  exception, 
and  this  exception  left  before  the  wound  was  entirely  healed, 
because  it  took  so  long. 

It  is  sometimes  difficult  to  find  the  internal  opening  either 
with  the  finger  or  with  a  probe.  In  such  cases  as  these  do  not 
take  it  for  granted  that  it  is  a  blind  fistula,  but  dry  the  finger, 
pass  it  inside  the  rectum,  throw  iodine  through  the  opening, 
and  as  it  oozes  through  you  will  find  the  finger  stained,  show- 
ing an  internal  opening  exists.  If,  however,  you  get  no  stain 
on  the  finger,  you  may  be  pretty  certain  that  the  mucous  mem- 
brane of  the  bowel  is  intact.  Many  other  staining  fluids  can 
be  utilized  for  this  purpose.  [H2  O2  is  excellent. — Ed.] 

In  a  case  where  there  is  a  multiple  fistula  the  treatment  is 
the  same,  except  that  each  tract  must  be  followed  very  care- 
fully to  its  terminus.  Occasionally  you  will  find  at  what  ap- 
pears to  be  the  terminal  end  an  opening  leading  off  into  the 
tissues  in  some  other  direction.  With  a  soft  probe  you  can 
outline  these  offshoots  and  treat  them  accordingly. 

Every  variety  of  fistula  should  be  thoroughly  eradicated 
by  removing  all  the  hardened  tissue  wherever  found,  and  it  is 
impossible  to  heal  the  wound  so  long  as  a  vestige  of  it  remains. 


ORIFIC1AL   SURGERY.'  335 

Many  modes  of  treatment  have  been  and  are  recommend- 
ed, the  elastic  ligature  being  highly  recommend- 
ed in  the  text  books.  But  I  have  seen  at  least  one  very  dis- 
astrous result  following  its  use.  The  sphincter  muscle  was  sep- 
arated widely  and  the  tissues  surrounding  the  anus  so  softened 
that  they  retained  very  little  of  their  former  integrity  and 
taxed  all  the  resources  of  the  surgeon  to  bring  the  parts  into 
anything  like  a  normal  condition.  For  this  reason  I  would 
place  it  in  the  same  class  as  the  ligation  of  hemorrhoids — out 
of  date. 

When  handling  a  fistula  all  the  points  of  irritation, 
whether  pockets,  papilla1,  hemorrhoids,  fissures,  ulcers,  etc., 
which  the  surgeon  may  observe  at  the  lower  part  of  the  bowel, 
should  be  eradicated  before  the  work  is  complete,  as  they  tend 
to  handicap  the  healing  of  the  wound  by  abnormal  contraction 
of  the  sphincter  muscles. 

CHAPTER  XLIII. 


STRICTURES  AND  ULCERS  OF  THE  RECTUM. 


E.   H.   PRATT,   M.   D. 


ORGANIC  STRICTURES. 


They  are  not  common.  Their  origin  is  some  form  of  ulcer- 
ation,  usually  syphilitic  or  cancerous,  although  stricture  of  the 
rectum  may  occur  from  inflammatory  processes  following  ab- 
scesses or  injuries.  They  may  be  located  at  any  point  in  the 
rectum  from  the  anus  to  the  junction  of  the  rectum  with  the 
sigmoid  flexure  of  the  colon.  They  may  take  the  form  of  one 
or  more  constricting  bands  or  narrow  the  calibre  of  the  entire 
rectum.  They  may  exist  in  any  form  or  to  any  extent  in  a 
rectum  which  is  movable  or  in  one  which  is  held  in  the  firm 
grip  of  inflammatory  products.  They  may  extend  around  the 
entire  circumference  of  the  gut  or  appear  only  on  one  side  of 
its  lumen. 


336  ORIFIGTAL   SURGERY. 

Strictures  of  cancerous  origin  usually  surround  the  entire 
circumference  of  the  intestine  when  first  observed,  and  their 
favorite  location  is  at  the  upper  end  of  the  rectum.  Those  re- 
sulting from  syphilitic  ulceration  may  narrow  the  calibre  of 
the  intestine  at  one  point  or  may  extend  the  whole  length  of 
the  rectum,  constricting  the  canal  irregularly  at  different 
places. 

In  all  cases  of  stricture  of  the  rectum,  whether  syphilitic, 
cancerous  or  traumatic,  the  last  inch  will  be  found  more  or 
less  completely  disorganized  and  will  call  for  the  attention 
of  the  orificial  surgeon.  If  the  stricture  is  low  down  in  the 
rectum  and  the  tissues  are  movable,  it  is  better  to  perform  the 
high  American  and  remove  the  entire  mass  of  cicatricial  tis- 
sue, especially  if  it  completely  encirle  the  intestine.  Where  this 
is  impossible,  however,  the  American  operation  should  not  as 
a  rule  be  performed  until  a  thorough  effort  has  been  made  to 
correct  the  difficulty  by  the  aid  of  curette,  scalpel,  bougies  and 
medication ;  as  the  oft  repeated  treatments  which  the  stricture 
would  call  for  would  interfere  with  the  healing  of  the  Ameri- 
can and  be  rendered  unnecessarily  painful.  In  bad  cases  of 
stricture  the  slit  work  is  usually  preferable.  If  the  origin  of 
the  stricture  be  cancerous,  the  relief  from  the  orificial  work, 
dilating,  curetting  and  packing,  and  even  from  extirpation, 
where  it  is  possible,  of  the  strictured  portion  will  be  merely 
temporary  and  colotomy  will  be  needed  sooner  or  later  in  order 
to  make  the  few  remaining  days  of  the  unfortunte  patient  even 
tolerable.  Although  I  have  known  of  a  few  eases  where  cancer- 
ous stricture  located  at  the  upper  end  of  the  rectum  has  been 
successfully  held  in  check  by  curettings,  dilatations,  packings 
and  injections  with  medicated  solutions  for  from  two  to  five 
years,  yet  these  are  exceptional  cases. 

Strictures  from  syphilitic  origin,  however  extensive  and 
formidable  the  appearance,  usually  result  satisfactorily  after 
persistent  and  careful  surgical  attention.  They  are  more  likely 
than  those  of  cancerous  form  to  be  located  in  the  vicinity  of 
the  anus  and  are  consequently  easier  of  access. 

In  a  case  of  stricture  located  more  than  three  inches  from 
the  anus  great  care  must  be  taken  in  either  curetting,  cut- 


ORIFIGIAL   SURGEKY.  337 

ting  or  dilating  not  to  rupture  the  intestine,  as  the  peritoneal 
cavity  is  liable  to  be  entered  and  poisonous  matter  be  carried 
into  it.  An  opening  made  in  the  intestine  or  the  peritoneal 
cavity  by  a  bougie  is  not  necessarily  fatal,  and  the  danger  will 
be  in  proportion  to  infectiousness  of  the  tissues  punctured. 
Large  bougies  have  been  pushed  through  the  rectum  into  the 
abdominal  cavity  in  cases  of  atrophy  of  the  rectum  without 
the  slightest  ill  effects.  At  the  same  time,  less  formidable 
wounds  through  more  poisonous  structures  have  proved  speed- 
ily fatal.  At  any  rate,  great  care  is  to  be  exercised  in  hand- 
ling the  upper  part  of  the  rectum.  Lower  down  in  the  organ, 
cutting,  rupturing  and  lacerating  intestinal  walls  is  not  so  se- 
rious a  matter,  the  main  danger  being  one  of  hemorrhage, 
which  is  usually  easily  controlled  as  it  is  readily  brought  with- 
in observation,  when  it  is  a  simple  matter  to  seize  the  bleeding 
points  with  artery  forceps  and  ligate  or  torsion  them. 

In  any  rectal  case,  stricture  or  otherwise,  after  the  pa- 
tient is  anesthetized  and  placed  in  position  the  first  rectal 
exploration  should  be  a  digital  one.  If  a  stricture  be  encount- 
ered and  situated  within  reach,  one  or  two  fingers  of  the  ex- 
ploring hand  may  be  employed  as  a  dilator.  If  a  smooth,  nar- 
row band  of  cicatricial  tissue  is  all  that  narrows  the  calibre 
of  the  intestine  this  may  be  nicked  posteriorly,  after  which  the 
tissues  can  be  torn  through  with  the  fingers,  bougies  or  rectal 
speculum  at  the  discretion  of  the  operator.  When,  however, 
the  stricture  is  a  longer  one  and  the  surface  is  covered  with  un- 
even growths  of  offending  tissue,  the  curette  may  be  freely 
employed  to  accomplish  its  removal.  If  the  lower  part  of  the 
rectum  be  in  a  normal  condition  and  the  stricture  is  at  its  up- 
per portion  and  at  the  same  time  movable,  T  forceps  or  tenacu- 
la  may  be  brought  into  service  to  invaginate  the  gut  so  as  to 
bring  the  stricture  within  reach.  Traction  can  be  made  upon 
these  instruments  by  assistants  while  the  surgeon  explores  with 
his  index  finger,  with  bougies  or  sigmoid  speculum,  according 
to  the  demands  of  the  case.  Through  poor  judgment  or  acci- 
dent should  the  intestine  be  torn  at  this  point  so  as  to  expose 
the  peritoneal  cavity  the  opening  should  be  immediately 
stitched  with  catgut  sutures.  Great  judgment  is  required  in 


338  OBIFIC1AL    SURGERY. 

these  manipulations  to  adapt  the  amount  of  traction  and 
handling  to  the  integrity  of  the  tissues  so  as  to  accomplish 
the  object  of  the  surgical  procedure  and  at  the  same  time 
avoid  the  dangers  of  undue  violence. 

EXTIRPATION  OF  THE  RECTUM. 

This  is  not  a  proper  subject  for  present  consideration,  and 
it  is  so  satisfactorily  treated  of  in  the  standard  text-books  that 
even  if  it  were  germane  to  our  present  theme  it  would  be  an 
unnecessary  affliction  upon  the  readers  to  publish  a  considera- 
tion of  this  subject,  as  we  have  nothing  new  to  suggest  except, 
perhaps,  that  where  resection  of  the  gut  is  contemplated  it  is 
well  to  save  the  sphincters,  so  that  the  patient  may  be  able  to 
retain  control  of  the  bowels.  It  is  quite  possible  in  some  cases 
to  split  the  sphincters  anteriorly  and  posteriorly,  resect  the 
diseased  portion  of  the  rectum  if  it  be  freely  movable,  and  at- 
tach the  separated  extremities  of  the  intestines  together  so  as 
to  completely  fill  in  the  gap  and  then  re-unite  the  sphincters 
at  their  separated  points.  The  cases  which  make  this  opera- 
tion possible  are  exceedingly  rare  but  very  satisfactory  for  the 
time  being.  Such  cases,  however,  are  usually  cancerous  and 
are  prone  to  recur  after  a  few  months,  or  at  most,  years. 

In  selecting  bougies  for  treatment  of  strictures  the  soft 
rubber,  olive-tipped,  French  bougies  with  a  canal  in  the  cen- 
ter are  most  desirable.  The  central  canal  is  especially  valu« 
able  in  the  treatment  of  cases  in  which  the  stricture  is  located 
high  up.  In  such  cases  the  folds  of  the  rectum  frequently  ob- 
struct the  passage  of  the  bougie,  and  it  is  a  material  aid  to 
its  employment  to  expand  the  rectum  with  tepid  water,  as 
can  easily  be  done  by  inserting  the  nozzle  of  a  syringe  into 
the  outer  extremity  of  the  canal  of  the  bougie.  After  the  gut 
is  well  distended  the  bougie  is  the  more  readily  guided  into  its 
proper  channel,  and  when  its  olive  tip  is  once  engaged  the  fur- 
ther progress  of  the  bougie  through  the  stricture  is  made  with 
comparative  ease.  The  following  is  a  cut  of  the  instrument: 

Larger  and  larger  sizes  of  bougies  should  be  employed  at 
the  time  of  the  operation  until  further  dilatation  of  the  intes- 
tine would  rupture  it.  In  the  subsequent  treatment  of  stric- 


ORIFICIAL    SURGERY. 


339 


ture  of  the  rectum  these  bougies  are  indispensable.  It  is  desir- 
able not  only  to  force  them  through  the  stricture,  but  to  per- 
mit them  to  remain  in  situ  for  from  fifteen  minutes  to  two 
hours  according  to  the  irritability  of  the  case.  The  steady 


FRENCH   BOUGIE. 

pressure  of  the  instrument  compels  a  change  in  the  circula- 
tion of  the  part  and  excites  a  healthier  action  throughout  the 
tissues,  as  a  result  of  which  stimulation  and  absorption  of  the 
inflammatory  products  follow.  The  bougies  in  some  cases  may 
be  used  daily  while  in  others  it  would  be  harmful  to  employ 
them  oftener  than  once  in  two  weeks,  according  to  the  state  of 
irritability  of  the  rectum  existing  at  the  time  of  their  em- 
ployment. 


PRATT  SIGMOID  SPECULUM. 

In  some  cases,  either  following  the  bougies  or  instead  of 
them,  the  new  sigmoid  speculum  which  I  have  lately  devised, 
and  of  which  the  following  is  a  cut,  will  be  found  a  very  ser- 
viceable instrument.  It  should  not  be  used  where  a  fissure  of 
the  tissues  has  already  been  started  as  there  is  danger  of  pro- 
ducing a  lacerated  wound  into  the  peritoneal  cavity.  No  rules 
for  the  use  of  either  the  curette  or  bougie,  or  even  one's  fin- 
ger, can  be  laid  down.  In  either  case  the  treatment  must  be 
individualized  and  surgical  judgment  employed. 


340 


ORIFIG'IAL    SURGERY. 


After  dilating  with  first  the  fingers,  then  the  bougies,  and 
lastly  the  sigmoid  speculum,  if  it  be  employed.  It  is  well  to 
hold  the  tissues  apart  by  means  of  a  sigmoid  plug  made  of  a 
long  strip  of  surgical  wool  which  may  or  may  not  be  rolled  in 
antiseptically  prepared  china  silk  and  medicated  according  to 
the  judgment  of  the  surgeon.  This  can  be  introduced  by 
means  of  Hall's  sigmoid  forceps  and  the  speculum.  The  fol- 
lowing is  a  cut  of  a  plug  for  the  upper  part  of  the  rectum,  held 
in  the  grasp  of  a  pair  of  Hall's  forceps  and  ready  for  carrying 
into  position.  This  is  best  done  through  the  sigmoid  speculum, 


WOOL,  PLUG. 

although  occasionally,  where  the  tissues  are  very  friable  and 
the  employment  of  the  speculum  would  be  dangerous,  a  small 
plug  can  be  carried  under  the  guidance  of  the  index  finger  of 
the  disengaged  hand  well  into  position  without  its  aid.  The 
plug  may  be  left  separating  the  walls  of  the  stricture  for  a 
length  of  time  varying  from  a  few  hours  to  a  day  or  so,  accord- 
ing to  circumstances.  The  plug  is  secured  at  one  extremity  by 
a  piece  of  silk  thread.  This  thread  should  be  of  sufficient 
length  to  permit  of  its  protrusion  from  the  anus  at  least  three 
or  four  inches,  as  there  is  such  a  thing  as  reversed  peristalsis 
and  it  has  frequently  happened  that  the  plug,  string  and  all, 
have  been  retracted  well  into  the  intestine  and  occasioned  no 
inconsiderable  amount  of  anxiety.  Of  course  no  great  harm 


ORIFICTAL   SUBGEKY.  341 

would  be  done,  as  eventually  a  vis  a  tergo  of  accumulated  fecal 
matter  would  insure  its  final  discharge.  But  it  is  better  to  re- 
tain possession  of  it  so  that  it  can  be  removed  at  the  discretion 
of  the  surgeon.  The  plug  can  be  medicated  as  desired,  al- 
though it  is  not  our  intention  in  the  present  series  of  articles 
to  mention  the  use  of  drugs,  either  locally  or  internally,  deem- 
ing it  but  proper  as  we  are  writing  for  all  schools  of  medicine, 
to  leave  this  much-vexed  question  untouched.  Still  there  are 
four  local  applications  which  are  so  efficacious  in  cases  of  can- 
cer or  syphilitic  affections  that  1  am  sure  no  one  will  be  offend- 
ed at  my  mention  of  them.  They  are  mentioned  in  the  order 
of  their  apparent  value  as  gleaned  from  an  extensive  experi- 
ence :  Bovinine,  magnetic  rock  oil,  listerine  and  hydrastis 
canadensis.  The  first  three  may  be  employed  full  strength, 
saturating  the  plug  with  them  freely  before  its  introduction. 
The  hydrastis,  however,  should  not  be  used  stronger  than 
twenty  or  thirty  drops  to  a  quart  of  water. 

In  bad  cases  of  stricture  several  successive  treatments 
may  be  required  under  an  anesthetic,  at  varying  intervals,  the 
length  of  which  is  to  be  determined  by  the  improvement  in  the 
case,  it  being  a  universal  surgical  rule  to  let  well  enough  alone, 
and  while  the  patient  is  gaining  to  a  satisfactory  degree  to  per- 
mit him  to  keep  on  doing  so  unmolested  by  surgical  inter- 
ference. 

SPASMODIC  STRICTURES. 

Spasmodic  strictures  of  the  rectum  are  usually  located 
either  at  the  amis  or  at  the  junction  of  the  rectum  with  the 
sigmoid  flexure  of  the  colon,  occasionally  somewhere  between 
these  points.  Spasmodic  stricture  of  the  anus  is  the  common- 
est, most  unobtrusive,  and  yet  most  mischievous  affliction  of 
disordered  humanity.  At  this  point  of  the  intestinal  tract  the 
largest  part  of  the  rectum  is  suddenly  constricted  into  the  nar- 
rowest portion.  Its  veins  sustain  the  entire  weight  of  the  blood 
columns  in  the  portal  circulation,  and  are  consequently  ex- 
ceedingly prone  to  congestion.  It  is  systematically  distended, 
rasped,  bruised,  scratched,  and  not  infrequently  torn  by  rough 
concretions  of  fecal  matter  which  are  forced  through  it.  It  is 


342  ORIFIC1AL   SURGERY. 

never  examined  or  put  in  repair  or  subjected  to  the  slightest 
attention  except  in  extreme  cases  of  distress;  and  yet  it  is  so 
uncomplaining  an  organ,  so  far  as  the  language  of  pain  is  con- 
cerned, that  its  membrane  can  suffer  a  surprising  degree  of 
disintegration  and  present  various  forms  of  serious  pathology 
without  even  attracting  the  attention  of  its  possessor. 

The  lower  inch  of  the  rectum  is  doubly  guarded:  An  ex- 
ternal sphincter  constructed  of  voluntary  muscular  fibers  sup- 
plied by  the  cerebro-spinal  system,  and  consequently  under  the 
control  of  the  will,  and  about  an  inch  higher  a  large  bundle  of 
circular  fibers  of  the  involuntary  type,  supplied  by  the  sym- 
pathetic nerve  and  consequently  acting  unconsciously  so  far  as 
bodily  sensations  are  concerned.  It  is  at  this  upper  part  of 
the  last  inch  of  the  rectum  right  within  the  grip  of  the  internal 
sphincter,  where  the  spasmodic  strictures  are  most  common  and 
most  serious;  most  common  because  they  are  painless  and  un- 
noticed; most  serious  because  the  strictured  condition  is  in- 
duced by  any  pathological  state  of  the  lining  membrane,  so 
that  sympathetic  force  is  wasted  prodigally  in  two  ways: 
First,  by  the  nerve  power  whieh  it  takes  to  unremittingly  hold 
in  undue  tension  the  sphincter  muscle ;  and  second,  by  the  fact 
that  in  its  spasmodic  action  it  is  gripping  down  upon  diseased 
terminal  nerve  fibers  which  are  distributed  upon  the  diseased 
mucous  surface. 

If  the  stricture  be  of  long  standing  so  that  the  muscle  is 
unduly  thickened  and  shortened,  it  may  be  necessary  after 
pruning  the  mucous  membrane  of  pockets,  papillae  and  hem- 
orrhoids to  make  a  submucous  section  of  the  sphincters.  This 
should  always  be  accomplished  laterally.  In  performing  the 
operation  a  strip  of  mucous  membrane  at  least  half  an  inch 
wide  must  be  left  intact  upon  one  side  of  the  rectum.  The  bi- 
valve speculum  is  then  to  be  introduced  and  its  blades  suf- 
riciently  separated  to  put  the  sphincters  in  a  condition  of  firm 
tension.  A  sharp  pointed  bistoury  is  then  to  puncture  the  skin 
at  the  margin  of  the  anus.  Through  this  opening  a  blunt 
pointed,  narrow  bladed  bistoury  is  to  be  entered  and  made  to 
pass  perpendicularly  outside  of  the  sphincters,  its  flat  surface 
being  toward  the  intestine.  The  index  finger  of  the  hand 


ORIFIC1AL   SURGERY.  343 

which  is  not  employed  with  the  knife  should  now  be  introduced 
into  the  rectum  and  curved  around  the  upper  border  of  the  in- 
ternal sphincter,  and  while  held  in  this  position  the  knife  is 
to  be  pushed  upward  until  its  dull  point  can  be  felt  by  the  in- 
serted finger.  The  knife  should  be  crowded  upward  until  it 
pierces  the  muscular  coat  of  the  intestines,  leaving  nothing  to 
separate  the  end  of  the  knife  from  the  point  of  the  finger  but 
the  mucous  lining  of  the  intestine.  The  cutting  edge  of  the 
knife  is  now  to  be  turned  toward  the  gut,  and  as  the  handle 
is  pushed  outward  and  the  knife  withdrawn,  the  point  of  it  is 
to  be  kept  in  close  contact  with  the  finger  which  has  been  in- 
serted into  the  bowel,  so  that  the  muscular  fibers  can  be  com- 
pletely severed  while  the  finger  and  knife  are  approaching  the 
anus  simultaneously.  If  all  the  fibers  are  not  cut  by  the  first 
effort  the  knife  can  .be  re-entered  and  the  work  completed. 
In  this  procedure  both  the  sphincters  are  severed  as  usually 
both  of  them  are  strictured.  I  have  never  known  this  proced- 
ure to  induce  a  permanent  condition  of  incontinence  of  the 
feces  and  have  never  had  to  regret  its  employment.  Cases  call- 
ing for  it,  however,  are  not  common,  as  in  a  great  majority  of 
anal  spasms  dilatation,  when  accompanied  with  a  proper  hand- 
ling of  the  lining  membrane  of  the  intestine — not  forgetting 
the  intimate  relation  between  the  sexual  organs  and  the  rectum 
and  the  consequent  necessity  for  correcting  all  morbid  condi- 
tions of  the  sexual  organs  at  the  same  time — is  sufficient  to 
effect  a  permanent  relief. 

Spasmodic  constriction  of  the  upper  part  of  the  rectum 
is  due  to  one  of  two  causes :  The  presence  of  an  ulcer,  which 
is  exceedingly  rare  except  in  cases  of  syphilitic  origin,  and 
some  disorder  of  the  sexual  apparatus.  In  the  female  it  is  usu- 
ally the  internal  os  uteri,  or  a  condition  of  retroflexion  or 
retroversion ;  in  the  male  it  is  prostatic  irritation.  When  the 
stricture  results  from  ulceration  of  the  rectum,  the  repair  of 
the  last  inch  of  the  rectum,  curetting  and  cauterizing  of  the 
ulcerated  surface  and  thorough  dilatation  of  the  sphincters  by 
means  of  the  sigmoid  speculum  will  readily  afford  permanent 
relief.  Where  the  trouble  is  due  to  sexual  disorders  it  is  worse 
than  needless  to  persevere  with  attention  to  the  rectum,  as  the 


344  ORIFIC1AL   SURGERY. 

stricture  will  be  perpetually  reproduced  until  the  cause  is  re- 
moved. Such  cases  will  teach  the  rectal  specialist  that  he  must 
be  a  good  orificialist  in  order  to  handle  the  rectum  successfully. 
The  great  problem  of  reflexes  perpetually  confronts  the 
rectal  surgeon.  Where  the  cause  of  the  rectal  spasm  has  been 
apparently  removed  and  induced  nerve  tension  continues  to 
stimulate  undue  contraction,  the  secondary  faradic  current  of 
electricity  applied  by  means  of  a  bipolar  electrode  is  invalu- 
able. An  electrode  constructed  and  employed  by  Dr.  C.  A. 
Weiriek  has  proved  so  serviceable  that  a  cut  of  it  is  here  in- 
troduced. 


RECTAL  ELECTRODE. 

The  rounded  end  is  metallic,  the  long  staff  which  pro- 
ceeds from  it  is  made  of  rubber-covered  spiral  spring  wire 
which  not  only  secures  flexibility  of  the  electrode  but  conducts 
the  current  to  the  metallic  ball  so  as  to  constitute  it  one  of  the 
electrodes.  The  other  electrode  consists  of  half  an  inch  of 
metallic  band  grasping  the  outer  surface  of  the  rubber  tubing 
at  a  variable  distance  from  the  metallic  ball.  Into  a  hole  in 
this  band  the  other  pole  of  the  battery  is  attached.  Both  the 
electrodes  are  to  be  introduced  into  the  rectum.  The  pole  is 
to  be  buried  as  far  as  the  stricture,  while  the  metallic  band 
is  retained  within  the  grip  of  the  anus.  As  soon  as  the  elec- 
trodes are  in  proper  position  the  battery  is  started.  The  posi- 
tive pole  is  connected  with  the  metallic  ball  and  the  negative 
with  the  metallic  band.  The  treatment  should  not  be  given 
oftener  than  every  other  day  and  in  some  cases  a  longer  in- 
terval is  desirable. 

In  all  cases  of  stricture  of  the  rectum,  whether  organic 
or  spasmodic,  orificial  work  should  accompany  or  precede  the 
treatment  of  the  stricture,  as  satisfactory  results  cannot  other- 


OBIFIG1AL    SURGERY.  345 

wise  be  permanently  secured,   especially  in   stricture   of  the 
spasmodic  variety. 

ULCERATION. 

The  subject  of  ulceration  of  the  rectum  has  been  prac- 
tically covered  in  what  we  have  said  of  strictures  and  so  will 
need  no  more  consideration.  They  are  to  be  curetted,  cauter- 
ized and  medicated  locally  and  internally.  When  practicable 
it  is  good  practice  to  dissect  them  out  and  close  the  wound 
with  catgut  sutures.  They  are  not  as  common  as  one  would  in- 
fer from  much  of  the  writing  upon  rectal  diseases. 

As  the  lower  openings  of  the  body  suffer  simultaneously, 
their  cure  demands  simultaneous  or  alternate  treatment.  One 
of  these  lower  openings  cannot  be  successfully  rescued  from 
pathology,  while  other  openings  are  permitted  to  remain  in  a 
pathological  state. 

CHAPTER  XLIV. 


F1STULJE-IN-ANO. 


E.   H.   PRATT,   M.   D. 


This  is  by  no  means  a  new  subject  for  professional  con- 
sideration for  extensive  discussions  of  fistula  can  be  found 
scattered  throughout  the  pages  of  medical  history  from  the 
very  beginning  of  the  first  volume. 

Although  the  trouble  is  an  old  one  so  far  as  the  human 
race  is  concerned,  there  are  some  new  suggestions  of  value 
as  to  its  treatment  which  have  resulted  from  the  professional 
progress  of  the  last  few  years.  We  do  not  aspire  in  the  present 
article  to  a  complete  and  exhaustive  discussion  of  the  subject 
of  fistula1,  desiring  merely  to  present  a  few  practical  sug- 
gestions in  connection  with  it,  premising  just  enough  gen- 
eral consideration  of  the  subject  to  ensure  a  clear  under- 
standing of  the  suggestions  to  be  made. 

The  common  division  of  fistnlae  into  internal,  external,  and 
complete  seems  to  us  quite  satisfactory.  The  internal  and 


346  ORIFIG1AL   SURGERY. 

external  fistulas  are  otherwise  known  as  blind  or  incomplete, 
as  they  open  upon  but  one  surface,  either  skin  or  mucous  mem- 
brane, whereas  the  complete  variety  open  upon  both  surfaces, 
thereby  making  a  small  but  false  passage  from  the  outside  of 
the  body  into  the  intestine.  The  inner  opening  of  the  com- 
plete fistulae  and  the  opening  of  the  internal  are  usually  lo- 
cated between  the  sphincters. 

As  to  internal  fistulae,  the  opening  is  into  the  intestine. 
In  the  case  of  external  fistulas,  the  opening  is  through  the  in- 
tegument in  the  vicinity  of  the  anus. 

Any  of  the  three  forms  of  fistulas  may  be  merely  tubular 
and  of  uniform  calibre,  or  they  may  be  sacculated  and  branch- 
ing like  the  limbs  of  a  tree. 

EXTERNAL  FISTULAE. 

External  fistulae  are  blind  tubes  or  pouches  imbedded  in 
the  areolar  tissue  about  the  anus  and  opening  upon  the  sur- 
face of  the  integument  by  one  or  more  mouths  in  the  vicinity 
of  the  anus,  sometimes  close  to  its  margin  and  sometimes  a 
few  inches  removed  from  it.  They  are  usually  relics  of  ischio- 
rectal  abscesses  which  have  degenerated  into  a  pus  tracks  or 
sinuses,  either  single  or  branching.  As  they  open  only  upon 
the  skin  surface  their  cure  does  not  involve  any  attention  what- 
ever to  the  rectum  proper.  Ischio-rectal  abscesses,  although 
at  the  time  of  their  occurrence  usually  regarded  by  the  pa- 
tients, and  sometimes  by  the  surgeon,  as  quite  formidable  sur- 
gical difficulties,  seldom  cause  any  trouble  and,  after  a  thor- 
ough evacuation  of  the  confined  pus  and  cleansing  of  the  cavity 
and  a  few  packings  of  iodoform  gauze,  are  permanently  cured. 
Occasionally,  however,  they  are  left  to  ulcerate  their  way 
through  the  integument  unaided  by  the  surgeon's  scalpel  and 
as  soon  as  a  small  opening  has  partially  relieved  the  pressure 
of  the  confined  pus  the  opening  again  closes,  to  yield  once  more 
only  upon  a  re-accumulation  of  the  purulent  matter  and  return 
of 'the  pressure  from  within.  A  repetition  of  this  process  per- 
mits the  burrowing  of  pus  in  many  directions  in  the  loose  are- 
olar tissue  about  the  anus,  or  results  in  a  thickening  of  the 
inflammatory  zone  which  limits  the  pus  cavity.  So  although 


ORIFIC1AL   SURGERY. 


347 


the  pus  ultimately  may  establish  an  avenue  of  exit  sufficient  to 
drain  the  cavity  with  comparative  freedom,  the  walls  of  the 
pus  sac  have  become  so  thoroughly  organized  as  to  fail  to  col- 
lapse and  solidify  when  they  cease  to  be  held  apart  by  an  ac- 


FIG,  1. 

Probe  passed  through  fistula  entering  in  labia  majora  near  clitoris 
and  coming  out  in  rectum  between  sphincters.  First  stage  of  American 
operation  performed.  T  forceps  retracting  integument.  Artery  forceps 
seizing  bleeding  points.  T  forceps  seizing  severed  margins  of  mucous 
membrane. 

cumulation  of  pus.  Especially  is  this  the  case  with  tubercu- 
lous subjects;  and  tubercular  degeneration  is  very  liable  to  af- 
fect the  inflammatory  zones  which  constitute  the  pus  walls  of 
these  ischio-rectal  abscesses.  There  is  an  intimate  nervous  con- 
nection between  the  organs  of  respiration  and  the  tissues  about 
the  anus.  The  abdomen  is  bounded  practically  by  two  dia- 


348  ORIFIG1AL    SURGERY. 

phragms;  an  upper  one,  which  separates  it  from  the  heart  and 
lungs,  and  a  lower  one,  which  forms  the  floor  of  the  pelvis,  the 
posterior  part  of  which  constitutes  the  tissues  which  support 
the  anus.  Like  a  pair  of  twins,  these  diaphragms  sympathize 
with  each  other  in  their  action.  Coughing,  sneezing,  laughing, 
breathing,  sighing,  speaking — every  effort  which  involves  the 
entrance  and  exit  of  air  into  the  lungs  calls  into  play  the  upper 
diaphragm.  It  rises  and  falls  in  the  regular  rhythm  of  respira- 
tion, or  contracts  suddenly  and  violently  as  in  coughing  or 
sneezing,  or  doubles  itself  into  profound  contortions  of  muscu- 
lar effort  in  laughing,  coughing,  etc.  And  as  surely  as  a  shad- 
ow clings  to  the  object  which  casts  it,  hugging  it  closely,  re- 
gardless of  the  rate  of  speed  or  its  direction,  so  surely  does  the 
lower  diaphragm  or  the  floor  of  the  pelvis  repeat  with  remark- 
able fidelity  both  the  rhythm  and  the  intensity  of  the  action 
of  the  upper  diaphragm*  This  sympathetic  and  mutual  activ- 
ity on  the  part  of  these  twin  structures  is  accomplished  by  in- 
timate nervous  connections,  which  can  be  readily  demonstrated 
upon  the  cadaver  or  gleaned  from  any  standard  work  upon  the 
human  anatomy,  or  verified  by  observations  upon  the  living 
body.  As  the  rapidity  and  depth  of  diaphragmatic  respira- 
tions are  instantaneously  echoed  by  the  pelvic  floor,  abnormal 
conditions  and  contractions  and  degrees  of  inactivity  and  im- 
mobility on  the  part  of  the  pelvic  floor  modify  to  the  exact  ex- 
tent of  their  existence  the  freedom  of  action  and  degree  of 
tension  of  the  upper  diaphragm.  These  two  diaphragms  are 
twins  for  life.  They  suffer  together  and  enjoy  together.  They 
work  together  and  they  play  together.  They  not  only  relax 
and  contract  together,  each  supporting  the  other,  but  they  suf- 
fer and  writhe  and  neglect  the  proper  performance  of  their 
functions  in  common.  This  is  the  reason  why  rectal  troubles 
are  so  prone  to  induce  affections  of  the  lungs,  and  also  why 
lung  troubles  aggravate  and  retard  the  recovery  of  rectal  dif- 
ficulties. The  fact  is,  that  patients  suffering  from  lung 
troubles  always,  without  exception,  present  upon  examination 
some  form  of  rectal  pathology,  and  the  lung  trouble  perpetn- 
ates  and  aggravates  the  rectal  disorder,  and  the  rectal  dis- 
order, on  the  other  hand,  aggravates  and  protracts  the  lung 


OBIPIC1AL    SURGERY. 


349 


trouble.  This  fact  has  not  been  fully  appreciated  by  the  medi- 
cal profession,  and  it  will  be  a  good  many  years  yet  in  all  prob- 
ability before  they  realize  the  importance  of  correcting  rectal 
pathology  as  an  aid  in  the  cure  of  all  forms  of  diseases  of 
the  lungs. 


Fro.  2. 

Grooved  director  passed  through  fistula.  Bistoury  in  position  for 
laying  open  the  track.  It  will  sever  the  external  sphincter.  Severed 
edge  of  integument  after  redundant  tissue  has  been  trimmed  away. 

An  exceedingly  common  form  for  rectal  diseases  to  assume 
in  cases  of  lung  trouble  is  some  form  of  fistula?.  This  fact  has 
Been  well  known  for  many  generations,  not  only  to  the  medi- 
cal profession  but  also  to  the  people  themselves.  By  the  ig- 
norant the  existence  of  fistula?  in  consumptives  has  been  re- 
garded as  an  outlet  for  the  tubercular  poison,  and  it  has  been 
deemed  dangerous  to  attempt  their  cure  in  such  cases.  The 
foundation  for  this  professional  and  public  fallacy  probably 
lies  in  the  fact  that  the  old  method  of  operating  upon  fistulas 
where  it  has  been  associated  with  weak  lungs  has  been  un- 
happy in  its  results,  and  therefore  was  deemed  meddlesome 
surgery.  The  reason  surgical  interference  with  this  difficulty 


350 


ORIFIC1AL    SURGERY. 


in  cases  suffering  from  lung  trouble  has  been  unfortunate  lies 
in  the  simple  fact  that  the  operators  did  not  recognize  other 
rectal  troubles  which  were  also  present,  and  as  they  gave  at- 
tention only  to  the  fistulas  their  patients  were  no  better  but 
rather  worse  for  their  interference. 


Fio.  3. 

T  forceps  retracting  severed  margins  of  fistula.  Tenacula  inserted 
in  floor  of  fistulous  track  and  employed  to  raise  and  straighten  the  track 
for  its  dissection.  Curved  pointed  scissors  with  one  blade  buried  be- 
neath fistulous  track  in  position  for  dissecting  it  out. 

The  variety  of  fistulas  occurring  in  tubercular  subjects  is 
more  apt  to  be  of  the  internal  or  the  complete  form  rather  than 
the  external,  although  the  external  variety  is  not  exempt  from 
association  with  lung  pathology.  The  external  variety  of  fis- 
tulas is  the  least  harmful  to  the  general  health  of  the  patient 


ORIFIC1AL    SURGERY.  351 

and,  although  occasionally  deeply  situated,  is  perhaps  the 
easiest  form  to  cure.  All  that  most  cases  require  is  a  generous 
external  opening,  a  thorough  curetting  of  the  fistulous  cavity 
or  track,  a  repeated  packing  with  iodoform  gauze  or  jute,  ac- 
cording to  the  requirements  of  the  case,  and  a  douching  with 
some  form  of  medicated  solution  such  as  bichloride  of  mercury, 
carbolic  acid,  calendula,  etc.,  until  solid  tissue  has  been  built 
up  by  the  granular  process  to  the  surface  of  the  integument. 
Where  the  wound  is  sluggish  and  the  granulations  unhealthy, 
an  occasional  curetting  and  cauterizing  with  the  actual  cau- 
tery, blue  vitriol,  nitrate  of  silver,  or  carbolic  acid,  may  some- 
times be  required  to  keep  the  granulations  sufficiently  healthy 
to  insure  permanent  and  satisfactory  repair.  A  valuable  meas- 
ure in  such  cases  is  the  occasional  application  of  iodine,  full 
strength,  or  the  daily  application  of  a  weakened  solution.  If 
these  few  suggestions  are  carefully  followed  little  trouble  will 
be  encountered  in  eradicating  thoroughly  and  completely  the 
form  of  fistula  known  as  external.  Sometimes,  however,  in 
cases  of  long  standing  the  fistulous  track  will  be  so  thickened 
and  hardened  that  it  will  be  necessary  to  remove  it  more  or 
less  completely  by  the  aid  of  tenaculum  and  scissors  in  order 
to  secure  a  healthy  granulating  surface. 

INTERNAL  AND  COMPLETE  FISTULA. 

The  internal  and  complete  varieties  are  not  so  easily  mas- 
tered, as  their  cure  involves  the  correct  handling  of  the  last 
inch  of  the  rectum,  and  also  the  sphincter  muscles.  The  in- 
ternal opening  of  both  these  forms  of  fistulas  is  in  a  large  ma- 
jority of  cases,  as  previously  mentioned,  in  the  space  between 
the  two  sphincters,  and  it  may  be  found  anywhere  around  the 
circumference  of  the  anus,  either  in  front  or  behind  or  on  either 
side.  It  is  quite  common  in  either  of  these  forms  of  fistula?  for 
pus  tracks  to  burrow  upward  as  well  as  downward,  and  in  a 
circular  horseshoe  form  around  the  anus,  as  well  as  in  either 
of  these  directions.  They  may  consist  of  single  tracks  or 
ramify  in  various  directions.  It  is  exceedingly  rare  to  find 
them  possessed  of  more  than  one  opening  upon  the  mucous 
membrane  surface,  and  as  it  is  usually  somewhere  in  the  last 

L_LH(£l£    Oi 


352 


ORIFIC1AL    SURGERY. 


inch  of  the  rectum,  their  successful  treatment  is  not  difficult 
if  they  are  properly  handled.  As  they  are  invariably  accom- 
panied with  other  forms  of  rectal  pathology,  the  first  step  in 
their  cure  is  the  performance  of  the  American  operation.  The 
last  inch  of  the  mucous  membrane  of  the  rectum,  which  will  be 
found  to  contain  their  internal  openings,  is  to  be  carefully 
and  thoroughly  dissected  away  after  the  manner  already 
described. 


FIG.  4. 

T  forceps  seizing  deep  covered  sutures.  Margins  of  skin  coapted  by 
continuous  catigut  suture.  Severed  margin  of  integument  prepared  for 
the  attachment  of  the  mucous  membrane  which  is  to  be  brought  down 
from  above  and  secured  to  it  by  a  continuous  catgut  suture,  thereby 
completing  the  American  operation. 

The  lower  part  of  the  severed  mucous  membrane  is  now  to 
be  seied  with  forceps  and  brought  well  into  view.  The  fistula 
can  then  be  tracked  in  all  its  ramifications.  If  it  be  a  blind  or 
internal  fistula  and  burrow  upward  by  the  side  of  the  rectum, 
the  sphincters  are  to  be  severed,  their  margins  held  apart  by 
T  forceps  so  as  to  bring  the  track  well  into  view,  when  it  is 
to  be  dissected  out  if  practicable,  or  curetted  and  packed  with 


0   38 3 J JOG 


ORIFICTAL   SURGERY. 


353 


iodoform  gauze  if  it  be  too  deeply  situated  for  complete  re- 
moval. The  sphincters  are  now  to  be  stitched  together  in 
front  of  the  packing  and  the  mucous  membrane  drawn  down 
and  carefully  attached  by  a  continuous  suture  to  the  severed 
margins  of  the  skin  around  its  entire  circumference.  This 
process  converts  the  internal  fistula  into  an  external  one,  which 
will  yield  very  readily  to  the  treatment  already  just  described 


FIG.  5. 

T  forceps  seizing  ligature.  Ligature.  American  operation  to  be 
completed  by  a  continuous  catgut  suture  fastening  together  skin  and 
mucous  membrane.  The  deep  sutures  beneath  the  fistula  are  now  to  be 
tied,  and  parts  dusted  with  quinine  or  iodoform  and  the  operation  is 
complete. 

for  that  variety.  In  case,  however,  the  blind  fistula  is  of  the 
horseshoe  variety,  its  track  is  to  be  completely  laid  open  and 
dissected  out,  after  which  the  American  operation  is  to  be  com- 
pleted. No  further  trouble  need  be  apprehended  from  the 
blind  fistula. 

In  the  complete  variety,  the  treatment  of  the  case  depends 
upon  the  extent  of  the  ramifications  of  the  pus  track.  If  it  be 
a  single  straight  track,  having  its  external  opening  near  the 
anus,  the  external  sphincter,  behind  which  it  invariably  passes, 


354  ORIFIC1AL    SURGERY. 

is  to  be  severed  either  with  a  pair  of  scissors  or  a  knife  upon 
the  surface  of  a  grooved  director,  and  while  the  extremities 
of  the  severed  muscles  are  held  apart  by  T  forceps,  the  track 
can  be  dissected  out,  after  which  the  muscle  and  margins  of 
the  track  can  be  carefully  brought  together  with  a  continuous 
catgut  suture.  The  American  operation  is  then  to  be  com- 
pleted. 

In  case,  however,  the  areolar  tissue  about  the  nates  has 
been  thoroughly  honeycombed  by  branching  sinuses,  the  fis- 
tula will  take  the  appearance  of  a  shrub.  Its  central  stem  will 
be  a  single  track,  which  has  one  internal  opening,  such  as  has 
been  described,  and  will  be  found  between  the  sphincters,  and 
numerous  branches  wandering  out  into  the  areolar  tissue  of 
the  buttocks  and  opening  upon  the  surface  of  the  skin  by 
apertures  varying  in  number  from  twelve  to  fifteen.  In  such 
cases,  after  treating  the  central  track  or  stem  of  the  fistula  as 
already  described  and  completing  the  American  operation,  each 
of  the  numerous  branches  of  the  sinus  is  to  be  dilated  by  grad- 
ed steel  sounds  and  for  this  purpose  the  graded  female  sounds 
are  satisfactory  instruments.  They  are  then  to  be  curetted 
and  tubed  with  soft  rubber  tubing,  or  packed  with  small  ropes 
of  jute.  Daily  cleansing  of  these  numerous  branching  sinuses 
will  be  needed  to  complete  the  cure.  Peroxide  of  hydrogen, 
bichloride,  iodine,  carbolic  acid,  calendula,  nitrate  of  silver, 
and  other  medicated  douches  will  be  found  serviceable  in  com- 
pleting their  eradication.  Dr.  Terry's  plan  of  douching  these 
sinuses  frequently,  and  never  employing  the  same  solution 
twice  in  succession,  thereby  surprising  the  parts  with  a  wash 
to  which  they  have  not  become  accustomed,  is  a  very  valuable 
one. 

The  accompanying  cuts  illustrate  the  method  of  handling 
the  simpler  variety  of  complete  fistula?.  There  are  several 
other  and  satisfactory  ways  of  operating  upon  fistulae  which 
we  will  not  take  the  time  to  describe.  If  the  fistulas  are  un- 
accompanied by  other  forms  of  rectal  difficulty,  it  will  be  bet- 
ter worth  our  while  to  give  these  our  first  consideration.  As 
the  last  inch  of  the  rectum  is  always  pathological  in  these 
cases,  the  American  operation  is  invariably  demanded,  and 


ORIFIC1AL    SURGERY.  355 

consequently  it  is  scarcely  worth  our  while  to  give  extended 
consideration  to  measures  which  we  do  not  deem  advisable. 

When  fistulas  are  healed  by  dilatation,  by  curetting,  by 
some  form  of  cautery,  or  by  a  thorough  system  of  douching 
and  medication,  as  it  is  frequently  possible  to  do,  other  forms 
of  rectal  pathology  accompanying  them  remain  uncorrected 
and  the  fistulae  are  prone  to  recur,  in  addition  to  the  fact  that 
the  cure  of  the  fistulae  in  such  cases,  does  not  save  the  patient 
from  the  nerve  waste  induced  by  the  contracting  of  the 
sphincters  upon  the  morbid  terminal  nerve  fibres  of  a  diseased 
last  inch. 

It  is  a  matter  of  common  experience  to  find  patients  suf- 
fering with  pulmonary  tuberculosis  who  are  afflicted  at  the 
same  time  with  rectal  fistula.  There  is  a  widespread  and  at  the 
same  time  erroneous  impression  that  the  presence  of  a  fistula 
is  conducive  to  the  longevity  of  the  consumptive  and  that  to 
cure  it  is  disastrous  to  the  patient.  This  impression  is  preva- 
lent not  only  with  the  laity,  but  among  the  less  enlightened 
members  of  the  medical  profession.  So  much  so  is  this  th(j 
case  that  where  a  consumptive  is  possessed  of  a  fistula  he  not 
only  has  the  impression  that  the  cure  of  the  fistula  would  pre- 
cipitate his  consumptive  tendencies  and  materially  shorten  his 
days,  but  a  large  percentage  of  the  medical  fraternity  are 
averse  to  operating  upon  the  fistula?  of  consumptives.  In  some 
cases  the  prejudice  goes  even  beyond  this,  and  it  is  even  be- 
lieved by  both  laymen  and  some  doctors  that  the  cure  of  a  fis- 
tula in  one  who  is  otherwise  apparently  well  is  liable  to  induce 
pulmonary  consumption.  It  has  been  frequently  rumored  that 
fistula  is  beneficial  to  consumptives,  and  a  few  medical  men 
who  entertain  this  idea  are  mistaken  enough,  and  have  the 
courage  of  their  convictions  to  such  an  extent,  that  when  cases 
of  consumption  who  have  no  fistula  apply  to  them  for  relief 
they  are  in  the  habit  of  establishing  fistulas,  believing  it  to  be 
for  the  best  interests  of  the  patients.  All  this,  of  course,  is 
most  thoroughly  wrong.  Most  cases  of  pulmonary  tuberculosis, 
sometimes  in  advanced  stages,  but  in  a  very  large  percentage 
in  the  earlier  stages  of  development,  are  easily  curable  by  the 
aid  of  orificial  methods,  and  those  who  have  anal  fistulae  are 


356  ORIFIC1AL    SURGERY. 

almost  uniformly  the  easiest  ones  to  cure.  The  experience  up- 
on which  these  erroneous  impressions  have  been  formed  comes 
probably  from  two  sources.  The  first  is  that  those  who  have 
operated  upon  fistulae  have  ignored  other  rectal  conditions 
present,  as  pockets,  papilla?  and  hemorrhoids,  operating  solely 
upon  the  fistulae,  so  that  the  patients  were  still  possessed 
of  rectal  trouble,  and  although  the  irritation  caused  by  the  fis- 
tulae might  be  removed  this  would  still  continue  its  baneful 
influence  upon  the  strength  of  the  patient,  and  tubercular  ten- 
dencies developing  after  the  operation  could  be  easily  laid,  by 
a  prejudiced  man,  to  the  work  done  for  the  cure  of  the  fistula, 
whereas,  in  reality,  it  was  the  uncorrected  rectal  troubles  that 
were  working  their  mischief. 

Another  cause  for  the  prejudice  against  operating  upon 
fistulae  comes  from  the  imperfect  manner  in  which  it  has 
heretofore  been  accomplished.  The  orthodox  manner  of  oper- 
ating upon  fistula?  which  has  been  in  vogue  for  generations 
past  and  which,  it  is  lamentable  to  state,  is  still  in  vogue,  is, 
either  with  or  without  the  aid  of  a  grooved  director  and  scis- 
sors or  knife,  to  lay  open  the  fistulous  track  from  its  one  or 
two  openings  upon  the  skin  surface  to  its  usually  single  open- 
ing upon  the  surface  of  the  mucous  membrane.  As  a  fistula, 
however,  invariably  passes  behind  the  external  sphincter,  and 
occasionally  the  internal,  in  this  operation  not  only  the  skin 
and  mucous  membrane  are  severed,  but  one  or  both  sphincters. 
The  bottom  of  the  wound  is  then  cauterized  with  actual  cautery 
or  caustic,  packed  with  gauze,  so  that  the  margins  of  the  wound 
can  be  kept  apart,  and  the  wound  is  made  to  granulate  from 
the  bottom.  This  antiquated  and  barbarous  proceeding  has  so 
many  and  weighty  objections  that  there  is  no  longer  the 
slightest  excuse  for  its  employment,  and  those  who  still  advo- 
cate this  method  should  be  brought  by  some  means  to  its  com- 
plete abandonment.  The  objections  to  this  method  are  that 
the  severing  of  the  sphincters  and  the  practice  of  keeping  them 
apart  in  this  way  until  the  wound  is  filled  from  the  bottom 
and  is  skinned  over  by  cicatrization  is  liable  to  induce  perma- 
nent incontinence  of  feces.  In  the  next  place,  when  the  opera- 
tion is  done  upon  patients  where  tuberculosis  is  already  well 


ORIFICIAL   SURGERY.  357 

seated,  the  wound  seldom  heals  and  the  patient,  instead  of  be- 
ing benefited  by  the  operation,  is  simply  furnished  with  an 
added  misery  to  contend  with.  But  the  third  and  best  reason 
is  that  there  are  several  better  ways,  which  should  be  familiar 
to  every  surgeon  who  essays  the  cure  of  rectal  fistuloe,  especi- 
ally in  consumptives. 

For  those  who  object  to  the  use  of  the  knife  there  is  a  sim- 
ple method  of  dealing  with  the  main  track  of  a  rectal  fistula 
by  means  of  the  actual  cautery  which  is  very  satisfactory. 
First  of  all,  before  the  fistula  is  treated,  the  rectal  speculum 
should  be  introduced  and  whatever  other  rectal  trouble  is 
found  present  should  be  attended  to.  Papillae  and  hemorrhoids 
should  be  removed,  fissures  should  be  dissected  out  or  curetted, 
scarified  and  cauterized,  hemorrhoids  should  be  excised,  and 
the  anus  property  dilated  to  the  extent  at  least  of  the  bivalve. 
In  dilating  the  anus,  a  series  of  secussions  with  the  rectal 
speculum  should  be  made  in  order  to  arouse  the  reactive  pow- 
ers of  the  patient  as  much  as  possible.  No  danger  need  be  ap- 
prehended in  the  employment  of  the  bivalve,  as  when  it  is  em- 
ployed to  its  full  capacity  it  will  not  rupture  the  sphincter 
muscles  or  induce  incontinence  of  feces.  Many  times,  indeed, 
dilatation  is  needed  beyond  the  capacity  of  the  rectal  bivalve, 
and  the  two  first  fingers  of  the  two  hands,  introduced  back  to 
back,  will  be  found  necessary  to  secure  a  proper  degree  of  di- 
latation. The  sphincters  should  not  be  stretched  to  the  point 
of  the  giving  way  of  their  fibres,  but  just  short  of  that.  After 
the  last  inch  of  the  rectum  has  been  thoroughly  examined  and 
properly  trimmed  and  dilated,  the  condition  of  the  fistula  is 
to  be  examined.  There  are  three  kinds  of  fistulas ;  one  opening 
into  the  rectum,  and  another  variety  which  opens  externally, 
while  a  complete  fistula  opens  upon  both  the  mucous  membrane 
and  skin  surfaces.  Complicated  and  complete  fistula?  usually 
have  one  internal  opening  and  several  external  openings  more 
or  less  widely  scattered  over  the  buttocks  and  perineum.  If 
the  case  be  one  of  internal  blind  fistula  it  will  be  necessary  to 
make  it  complete  by  making  an  opening  into  it  from  the  skin 
surface.  If  the  blind  fistula,  however,  is  of  the  external  va- 
riety, having  no  internal  opening,  it  will  not  be  necessary  to 


358  ORIFIG1AL    SURGERY. 

render  it  complete,  as  it  can  be  treated  easily  and  successfully 
without  disturbing  either  the  mucous  membrane  or  the  sphinc- 
ter muscles,  as  will  be  readily  understood  in  the  light  of  the 
operations  yet  to  be  described. 

If  the  case  is  a  complicated,  complete  fistula,  having  one 
internal  opening  and  several  external  openings,  the  methods 
of  procedure  which  we  are  about  to  describe  should  be  ap- 
plied to  the  main  track  of  the  fistula,  which  starts  from  the  in- 
ternal opening  and  the  various  branches  which  open  upon  the 
skin  surface  at  some  distance  from  the  anus  can  be  dilated, 
curetted,  and  tubed  or  packed,  and  easily  cured  after  the  main 
track  is  satisfactorily  dealt  with. 

The  internal  openings  of  all  forms  of  fistulae  are  almost 
invariably  to  be  found  between  the  two  sphincters  ani,  about 
half  an  inch  from  the  margins  of  the  anus.  They  are  usually 
located  laterally,  but  may  occur  anteriorly  or  posteriorly.  As 
the  treatment  is  practically  the  same  in  all  cases  their  loca- 
tion is  a  matter  of  surgical  indifference.  A  description  of  the 
manner  in  which  complete  rectal  fistulae,  which  is  the  simplest 
variety,  are  to  be  treated  will  be  an  adequate  guide  for  the 
treatment  of  all  other  forms  of  fistulae.  The  first  method  to  be 
considered  is  one  which  will  be  welcomed  by  those  who  are 
averse  to  the  employment  of  the  knife.  It  is  as  follows : 

A  grooved  director  is  entered  at  the  external  opening  of 
the  fistula,  passed  along  its  track,  and  carried  through  its  in- 
ternal opening  in  the  bowel,  when  the  end  of  the  instrument 
meets  the  finger  of  the  operator,  by  means  of  which  it  is 
dragged  downward,  brought  out  of  the  anus,  pushed  well 
through  the  fistulous  track,  so  that  its  point  can  rest  upon  the 
opposite  buttocks.  This  stretches  the  tissues  tightly  across 
the  grooved  director  and  changes  the  direction  of  the  track 
from  a  perpendicular  to  a  horizontal  one,  making  it  superficial 
and  easy  of  manipulation.  A  sharp-pointed  probe  is  now  made 
to  pierce  the  skin  at  a  point  equally  distant  from  the  anus  with 
the  external  opening  and  an  inch  distant  from  it  laterally, 
whichever  way  is  most  convenient,  and  carried  straight 
through  the  intervening  tissues  until  its  point  can  be  made  to 
emerge  at  the  internal  opening  of  the  fistula  at  the  side  of  the 


ORIFIC1AL    SURGERY.  359 

grooved  director.  The  sharp-pointed  probe  should  be  fur- 
nished with  an  eyelet  at  its  blunt  extremity,  which  should  be 
threaded  with  platinum  wire.  Three  or  four  inches  of  the  wire 
are  now  to  be  drawn  through  the  internal  opening  of  the  fis- 
tula, after  which  the  probe  is  to  be  carried  along  the  groove  of 
the  director  until  its  point  appears  at  the  external  opening  of 
the  fistula.  The  grooved  director  can  then  be  withdrawn  and 
traction  made  upon  the  probe,  dragging  the  wire  after  it.  In 
this  manner  a  piece  of  platinum  wire  will  be  carried  around 
a  triangular  piece  of  the  tissue,  whose  apex  is  the  internal 
opening  of  the  fistula,  whose  base  is  in  the  inch  of  integument 
which  marks  the  distance  between  the  external  opening  of  the 
fistula  and  the  point  at  which  the  probe  was  at  first  entered, 
and  whose  sides  are  formed,  one  by  the  fistulous  track  itself 
and  the  other  by  the  track  made  by  the  probe  as  it  found  its 
way  to  the  internal  opening  of  the  fistula.  Both  ends  of  the 
platinum  wire  are  now  to  be  attached  to  a  cautery  battery,  the 
current  turned  on,  and  the  triangular  tissue  embraced  by  the 
wire  is  to  be  severed  by  the  cautery.  This  proceeding  pro- 
duces a  conical-shaped  wound,  whose  apex  is  the  internal 
opening  of  the  fistula  and  whose  base  is  at  the  skin  surface. 
While  tenacula  are  holding  apart  the  lips  of  the  wound,  the 
cavity  is  to  be  packed  with  iodoform  gauze,  which  is  to  be 
untouched  for  two  or  three  days,  after  which  it  is  to  be  packed 
daily  until  the  wound  is  so  filled  by  granulations  as  to  be  no 
longer  a  cavity  and  the  cicatrization  of  its  surface  is  all  that 
remains  to  be  accomplished. 

A  second  method,  which  is  also  successful,  may  be  de- 
scribed as  follows :  After  administering  the  pruning  and  di- 
lating which  the  other  rectal  conditions  present  call  for,  the 
track  is  to  be  laid  open,  severing  completely  the  mucous  mem- 
brane, skin  and  muscular  structure  covering  the  track  just  as 
in  the  old  way  of  operating.  But  instead  of  leaving  the  track 
to  granulate  from  the  bottom  as  in  the  old  operation  it  is  to  be 
seized  by  tenacula  and  carefully  dissected  out,  after  which  the 
wound  is  to  be  closed  by  sutures,  the  muscle  or  muscles  should 
be  stitched  together  by  a  No.  3  catgut  and  the  skin  surface  co- 
apted  by  a  sub-cutaneous  sewing.  The  .  wound  should  bo 


360  ORIFIC'IAL    SURGERY. 

cleansed  and  a  dry  dressing  applied,  which  should  be  renewed 
every  day.  The  paroxysms  of  coughing  which  the  patient  un- 
dergoes are  liable  to  tear  the  tissues  apart  and  interfere  with 
the  healing  by  first  intention  in  a  large  number  of  cases,  al- 
though it  is  by  no  means  a  universal  experience,  and  sometimes 
it  is  necessary  to  apply  stitches  a  second  and  even  a  third  time 
in  order  to  secure  a  satisfactory  union  of  the  tissues.  For  this 
reason  the  following  operation  is  by  all  means  to  be  preferred 
and,  from  the  ease  with  which  it  can  be  accomplished  and  the 
success  which  invariably  attends  it,  it  is  by  all  means  the  most 
satisfactory  operation  yet  devised  for  the  cure  of  rectal  fistula 
in  pulmonary  tuberculosis. 

The  external  sphincter  is  a  flat  muscle,  varying  in  width 
from  one-half  to  an  inch,  and  completely  surrounding  the 
anus.  Its  fibres  are  interwoven  anteriorly  and  posteriorly.  The 
external  opening  of  a  fistula  is  usually  at  the  very  outer  mar- 
gin of  this  muscle.  A  circular  cut  is  to  be  made  along  the  out- 
er margin  of  the  muscle,  splitting  the  external  opening  of  the 
fistula  which  must  occupy  the  centre  of  the  incision.  The  cut 
is  to  be  continued  downward  deeply  into  the  tissues,  splitting 
the  fistulous  track  throughout  its  entire  length  as  far  as  its 
internal  opening.  As  the  fistulous  track  passes  behind  the  ex- 
ternal sphincter  muscle,  the  incision  enables  the  operator  to 
push  the  muscles  aside,  thereby  exposing  his  field  of  operation 
perfectly  without  doing  the  slightest  injury  to  the  muscle  it- 
self. The  lips  of  the  wound  are  now  to  be  held  apart  by  T- 
forceps  applied  on  either  side,  the  two  halves  of  the  track  are 
to  be  seized  by  tenacula,  and  dissected  away  by  scissors  or 
knife,  after  which  the  wound  is  to  be  closed  by  catgut  sutures. 
Before  the  closure  of  the  wound  it  is  well  to  expose  the  in- 
ternal opening  and  either  dissect  away  its  margin  by  the  aid 
of  tenaculum  and  scissors,  or  cauterize  it.  One  stitch  within 
the  anus  should  be  enough  to  completely  close  the  internal 
opening.  After  the  wound  has  been  closed  dry  dressings  are 
to  be  applied  and  the  patient  placed  in  bed. 

As  the  wound  is  not  within  the  grip  of  either  sphincter 
muscle  it  readily  heals  and  all  trace  of  the  operation  soon 
passes  away. 


ORIFICIAL    SURGERY.  361 


CHAPTER  XLV. 


RECTAL  FISSURES. 


E.    N.    CHANEY,    M.    D. 


A  rectal  fissure  may  result  from  an  ulcer,  or  from  a  lacer- 
ation of  the  walls  of  the  rectum  while  at  stool. 

It  differs  from  an  ulcer,  in  that  an  ulcer  involves  a  smaller 
amount  of  tissue;  if  it  increases  in  depth,  passes  through  the 
mucous  membrane  and  attacks  the  muscle,  we  call  it  a  fissure ; 
if  pus  exists  in  a  perceptible  quantity,  it  is  an  abscess;  if  its 
penetration  is  extensive  it  forms  a  fistula. 

A  painless  fissure  frequently  occurs  unknown  to  the  pa- 
tient. At  times  there  will  be  a  little  tenderness  and  hemor- 
rhage while  at  stool,  but  no  pain — this  usually  occurs  in  peo- 
ple whose  vital  forces  work  harmoniously. 

The  fissure  being  caused  by  a  sharp  cutting  portion  of 
stool,  will,  if  the  system  is  in  good  healing  condition,  incite  no 
more  ulceratiou  and  pain  than  if  the  same  abrasion  occurred 
on  the  exterior,  but  if  a  rectal  fissure  takes  place  within  a  per- 
son whose  vital  forces  are  at  variance  with  nature,  he  will  un- 
doubtedly become  desperate ;  and  the  attending  physician  may 
possibly  be  induced  to  consider  a  list  of  remedies  from  aconite 
to  zincum  before  relief  will  be  found. 

On  the  other  hand,  you  may  anesthetize,  cauterize,  dilate, 
divide  or  excise  the  fissure,  and  still  have  trouble,  sooner  or 
later,  unless  the  assistance  of  the  indicated  remedy  be  accepted. 

If  the  fissure  assumes  a  painless  character,  rectal  dilata- 
tion every  other  day,  to  a  degree  that  will  not  irritate  the  le- 
sion, should  be  employed. 

A  daily  cleansing  by  a  two-ounce  enema  of  some  good  an- 
tiseptic lotion  will  be  necessary.  Peroxide  of  hydrogen,  salt, 
listerine  and  similar  preparations  will  be  effective.  Occasion- 
ally patients  will  be  susceptible  to  a  few  of  these  combinations, 


362  ORIFIG1AL    SURGERY. 

which  will  demand  special  care  on  the  part  of  the  physician 
to  prevent  drug  pathogenesis  taking  place  through  the  local 
treatment. 

The  cleansing  should  be  followed  by  a  lubricating  oint- 
ment of  calendula,  or  any  medicine  noted  for  its  healing  qual- 
ity. Among  them  probably  the  most  popular  is  orificial  car- 
bolized  vaseline : 

I£ — White    vaseline    1  Ib. 

Paraffin    %   Ib. 

Carbolic  acid  8  m. 

Melt  and  stir  till  cool M. 

Apply  with  a  salve  injector,  but  do  not  allow  it  to  engage 
the  sphincters  ani ;  simply  the  anal  verge ;  then  force  the  vase- 
line up  into  the  rectum.  This  treatment  will  be  sufficient  to  heal 
not  only  the  painless  fissures,  but  also  any  existing  ulcers. 

If  the  fissure  is  irritable,  a  2  per  cent,  solution  of  cocaine 
with  1  per  cent,  of  phenol  in  distilled  water  may  be  required 
to  partially  anesthetize  the  raw  surface,  which  is  excruciat- 
ingly painful  when  simply  touched. 

Dilatation  should  be  the  first  procedure,  in  order  to  relieve 
the  impeded  circulation  of  the  congested  sphincters;  also  to 
provide  free  drainage  and  increase  the  calibre  of  the  bowel  to 
facilitate  the  making  of  applications  to  the  wound. 

Excessive  dilatation  should  not  be  resorted  to  at  any  time, 
as  it  is  liable  to  result  in  proctitis.  Neither  should  a  blunt 
dilator,  or  one  having  blades  be  used ;  nor  any  other  instrument 
possessing  features  that  will  irritate  the  wound ;  for  they  will 
increase  the  trouble  rather  than  alleviate  it. 

A  long,  pointed  aluminum  instrument,  well  heated  and  lu- 
bricated with  orificial  vaseline,  I  consider  most  effectual  for 
this  line  of  work. 

In  regard  to  the  frequency  of  the  treatments,  the  temper- 
ament of  the  case  must  decide.  In  some  cases  they  may  be 
given  every  day;  in  others,  every  other  day  or  once  a  week. 
The  dressing  and  care  should  be  the  same  as  for  painless  fis- 
sure until  complete  dilatation  is  accomplished  and  the  sore  is 
opened  to  its  depth;  then  treat  the  same  as  you  would  an  ex- 


ORIFICIAL   SURGERY.  363 

ternal  wound.  Swab  it  out  with  a  solution  causing  a  slight  ir- 
ritation, such  as  pyrozone,  or  peroxide  of  hydrogen  full 
strength,  or  a  1  per  cent,  solution  of  argentum  nitricum,  or 
any  non-toxic  preparation  that  will  induce  granulation. 

Our  object  to  fill  the  wound  from  the  bottom  to  a  level 
with  the  walls  of  the  rectum,  that  nature  may  extend  over  it 
a  new  mucous  membrane. 

The  applications  should  never  be  strong  enough  to  cauter- 
ize ;  as  the  burned  tissue  would  remain  as  a  scab  on  the  wound, 
sometimes  for  months,  and  before  healing  was  completed,  an 
evacuation  of  the  bowel  would  carry  away  the  protecting 
crust  and  again  establish  the  fissure,  much  to  the  discomfort 
of  the  patient.  At  the  same  time  cauterization  either  by  chem- 
icals or  electricity,  usually  culminate  in  cicatricial  tissue  which 
destroys  the  secretory  functions  of  the  mucous  membrane. 

Our  largest  and  most  irritable  fissures  appear  after  an 
operation  for  piles  or  ulcerations,  by  the  incision  method,  when 
the  after  dilatation  and  surgical  dressings  have  been  neglected. 
The  reason  for  this  is  that  the  operator  must  dip  into  the  mus- 
cular tissue,  in  order  to  remove  all  diseased  tissues  lying  be- 
low the  mucous  membrane.  Frequently  operators  prefer  to 
coapt  the  edges  of  the  fissure  with  a  suture  instead  of  using 
the  above  method.  This  may  allow  it  to  heal  by  first  intention, 
if  successfully  performed;  and  the  patient  would  experience 
relief  for  months  and  maybe  for  years;  but  the  work  has  re- 
duced the  caliber  of  the  sphincters  ani,  thereby  insuring  a 
return  of  a  similar  malady  at  the  same  site  or  some  other  por- 
tion of  the  rectal  wall,  with  less  provocation  than  formerly. 

Some  may  claim  that  filling  up  the  wound  with  granula- 
tions will  press  upon  the  terminal  nerve  fibers  and  benumb 
them;  this  will  be  impossible  if  complete  dilatation  be  main- 
tained while  the  process  of  repair  is  in  progress. 

Granulations  will  cover  the  exposed  nerves  as  well  as  if 
done  by  coapting  the  edges  of  the  wound;  that  is,  as  far  as 
hampering  nerves  and  exciting  reflex  symptoms  is  concerned. 
In  fact,  it  will  produce  no  more  trouble  than  circumcision  or 
an  unrepaired  perineum,  involving  the  same  amount  of  tissue. 


364  ORIFIG1AL    SURGERY. 

The  irritation  or  prostration  of  a  nerve  is  caused  by  a 
wound  being  involved  with  inflammation  and  suppuration  or 
impingement  by  adhesions  and  cicatricial  tissue. 

In  treating  a  case  of  fissure  by  gentle  dilatation,  it  pro- 
vides ample  time  to  thoroughly  execute  the  work  and  the  pa- 
tient has  been  relieved  constitutionally  as  well  as  locally. 

Auxiliary  measures  aside  from  the  orifieial  work  and  home- 
opathic remedy  may  be  found  in  the  hygienic  and  dietetic  care 
to  relieve  portal  and  mesenteric  congestion,  also  with  oste- 
opathy and  heat  to  assist  in  equalizing  the  general  circulation. 

The  remedies  most  frequently  indicated  for  fissure  will  be 
found  in  a  list  ordinarily  used  for  pelvic  congestion,  indi- 
gestion, biliousness,  and  catarrhal  troubles. 

In  selecting  a  remedy,  however,  allow  yourself  to  be  guid- 
ed by  the  peculiar  constitutional  symptoms  rather  than  by  the 
local  indications.  This  might  be  illustrated  by  a  single  case. 
An  allopathic  physician,  about  a  year  and  a  half  ago,  con- 
sulted me  in  regard  to  a  fissured  rectum  of  several  years' 
standing. 

He  received  gentle  dilatation  and  surgical  care  as  de- 
scribed in  the  above;  administered  nux  vomica,  arsenicum, 
and  sulphur  in  different  potencies,  as  the  local  symptoms 
would  indicate. 

Improvement  continued  for  three  Tveeks,  when  the  days 
that  he  received  dilatation  he  would  experience  an  unbearable 
cutting  pain  from  midnight  until  morning.  All  the  palli- 
atives found  in  a  drug  store  wouM  probably  have  been  in- 
sufficient to  give  him  relief  sooner.  At  least  he  tried  them  for 
six  hours,  because  not  homeopathy,  but  my  homeopathy  failed. 
These  pandemonium  exhibitions  took  place  about  three  times, 
when  an  ulcer  developed  on  his  nose  beneath  the  bow  of  his 
gold  spectacles.  As  the  ulcer  was  prone  to  appear  every  few 
weeks  for  years,  I  concluded  that  over-sensitiveness  to  the 
action  of  gold  was  with  him  an  idiosyncrasy.  This  with  his 
despondency,  diarrhea,  rectal  fissure,  and  ulceration  were  suf- 
ficient indications  for  aurum  metallicum,  one-thousandth  po- 
tency; of  which  he  received  three  powders;  one  every  twelve 


OBIFIC1AL    SUEGERY.  365 

hours.  By  this  time  we  had  opened  the  fissure  about  half  way, 
and  ever  after  the  dilating  went  on  with  but  little  discom- 
fort. The  ulcer  on  his  nose  was  healed  in  a  few  days  and  the 
fissure  in  a  few  weeks.  About  two  months  later,  the  ulcer  on 
his  nose  returned;  but  the  fissure  remained  quiescent.  We 
repeated  the  aurum  metallicum  .  and  the  ulcer  again  disap- 
peared quickly,  and  has  not  returned.  I  have  learned  recently 
that  the  patient  gained  thirty  pounds  in  weight  during  the  past 
year. 

CHAPTER  XLVI. 


DISEASES  OF  THE  RECTUM  AND  SIGMOID. 


C.   A.    PAULY,   M.    D. 


The  neurologists  of  today  feel  that  the  discovery  of  the 
neuron  theory  has  opened  the  way  for  a  more  comprehensive 
investigation  of  mental  and  nervous  diseases. 

The  rectal  specialists  feel  that  the  discovery  of  auto-in- 
fection from  the  intestinal  canal  has  opened  the  way  for  the  in- 
vestigation of  many  diseases,  the  pathology  being  obscure  at 
present.  The  progress  in  bacteriology  and  physiological  chem- 
istry has  gone  far  to  demonstrate  that  most  of  the  processes 
of  disease  in  general  are  due  to  toxic  substances  in  one  form  or 
another. 

The  poisons  found  generated  in  the  intestinal  canal  are 
the  result  of  chemical  putrefaction  or  fermentative  changes,  or 
the  action  of  bacteria.  We  may  have  auto-infection  from  any 
part  of  the  intestinal  canal.  It  is  claimed,  however,  that  the 
seat  of  infection  is  more  frequently  in  the  descending  colon, 
sigmoid  and  rectum.  The  peristaltic  action  of  the  colon  is 
very  sluggish,  and  the  sigmoid  being  the  most  constricted 
part,  obstruction  in  the  form  of  impaction  often  takes  place. 
If  the  impaction  is  permitted  to  remain  any  length  of  time, 
the  fecal  matter  is  relieved  of  its  watery  elements,  a  solid 
mass  remaining,  from  which  putrefaction  takes  place,  afford- 


366  OBIFIC1AL    SURGERY. 

ing  a  rich  field  for  the  multiplication  of  septic  muco-organisms 
and  their  products.  These  organisms,  with  their  ptomains, 
are  taken  up  by  the  circulation  and  lymphatics  and  carried  to 
the  different  parts  of  the  body,  causing  a  systemic  infection. 

Such  diseases  as  gout,  rheumatism,  diabetes,  chorea, 
chlorosis,  uremia,  asthma  and  the  different  skin  diseases  may 
be  generated  in  the  intestinal  canal.  Constipation,  compli- 
cated by  impaction,  is  the  most  frequent  cause  of  auto-infec- 
tion. Fecal  toxemia  manifests  itself  by  the  patient  complain- 
ing of  headache,  dizziness,  loss  of  appetite,  palpitation,  indi- 
gestion, etc.;  the  circulation  is  impaired;  pulse  may  be  full 
and  slow,  or  rapid  and  feeble ;  heart  excitable,  violent  palpita- 
tion; patient  is  drowsy,  feels  sleepy,  yet  rolls  and  tosses  all 
night,  rising  in  the  morning  feeling  weak  and  exhausted ;  the 
skin  has  an  unhealthy  color,  looks  yellow  or  muddy.  Some  of 
the  patients  suffering  with  fecal  toxemia  look  not  unlike  a  per- 
son with  a  malignant  growth. 

Constipation  and  impaction  are  also  factors  in  the  patho- 
logical changes  that  take  place  in  the  rectum  and  sigmoid.  By 
the  constant  irritation  of  the  confined  fecal  matter  the  mu- 
cous lining  becomes  inflamed  and  denuded.  Ulceration  fol- 
lows, and  by  the  aid  of  diarrhea,  a  prominent  symptom  of  ul- 
ceration,  the  fecal  mass  is  liquified,  and  its  poisonous  elements 
are  introduced  into  the  circulation  through  the  exposed  sur- 
face of  the  mucosa.  Ulceration  and  stricture  of  the  sigmoid 
form  a  good  culture  medium  for  muco-organisms,  and  favor 
putrefaction  and  fermentation.  As  a  result,  more  poisons  are 
generated  and  absorbed  than  nature  can  take  care  of,  the  sys 
tern  becomes  saturated,  and  the  skin  presents  the  sallow  ap- 
pearance which  is  usually  present  with  ulcer  of  the  colon. 
Many  of  the  mental  and  nervous  diseases  in  the  form  of  acute 
insanities  are  due  to  gastro-intestinal  disorders.  If  we  can 
keep  the  stomach  and  intestines  in  a  state  of  functional  activ- 
ity and  healthfulness,  the  majority  of  cases  of  nervous  dis- 
orders can  be  cured.  Melancholia  is  sometimes  induced  by 
auto-intoxication,  the  result  of  an  impacted  colon  or  sigmoid. 
When  the  impaction  has  been  removed,  the  melancholia  is  re- 
lieved. 


ORIFIC1AL   SURGERY.  367 

It  has  been  tersely  said:  "No  class  of  diseases  is  of  more 
importance  to  the  general  practitioner  than  those  occurring 
in  and  around  the  sigmoid,  rectum  and  anus."  Mr.  Allingham 
says:  "Diseases  of  the  rectum  are  among  the  most  common 
that  affect  civilized  humanity." 

While  the  rectum  and  sigmoid  are  not  the  seat  of  all  the 
ills  of  the  body,  yet  a  person  suffering  with  some  constitu- 
tional trouble,  and  who  at  the  same  time  has  a  pathological 
condition  in  the  rectum,  need  not  expect  to  get  well  until  the 
rectum  has  been  cured.  We  all  know  the  peculiarity  of  the 
nerve  supply  to  the  rectum  and  anus.  Many  neuroses  have 
their  origin  in  these  parts,  in  the  form  of  chorea,  hysteria  and 
neurasthenia.  In  cases  of  epilepsy,  the  convulsive  attacks  are 
kept  at  longer  intervals  by  keeping  the  sigmoid  and  rectum 
free  from  imperfection.  Violent  cases  of  mania  which  have 
developed  suddenly,  the  result  of  prolonged  constipation,  have 
been  restored  to  sanity  by  emptying  the  colon.  Fortunately 
the  intoxication  had  not  lasted  long  enough  to  impair  the  in- 
tegrity of  the  nerve  cells.  I  suppose  the  neuron  theory  is  cor- 
rect, but  a  better  understanding  of  the  pathogenesis  of  ner- 
vous and  mental  diseases  can  be  obtained  by  studying  the  brain 
and  nervous  system,  not  separately,  but  along  with  other  or- 
gans of  the  body,  becoming  more  familiar  with  the  pathologi- 
cal processes  that  operate  on  the  whole  organism.  You  are, 
perhaps,  more  familiar  with  the  diseases  and  their  treatment  in 
and  about  the  rectum  than  diseases  of  the  sigmoid.  Very  lit- 
tle has  been  written  on  sigmoidal  troubles.  They  have  been 
generally  considered  along  with  diseases  of  the  colon.  From 
the  structure  and  physiological  action  of  the  sigmoid,  it  is 
more  liable  to  pathological  changes  that  do  not  happen  higher 
up  in  the  bowels,  and  it  is  possible  for  it  to  be  the  seat  of  ob- 
scure diseases  that  are  not  recognized.  We  are  satisfied  that 
chronic  diarrhea  and  dysentery  often  have  their  origin  at  the 
sigmoid  instead  of  higher  in  the  colon. 

The  various  pathological  changes  found  at  the  sigmoid 
are  congestion,  inflammation,  ulceration,  stricture  and  can- 
cer. It  is  often  difficult  to  diagnose  just  what  the  condition 
is.  The  symptoms  are  misleading;  diarrhea  is  most  frequent, 


368  ORIFICIAL    SURGERY. 

yet  constipation  may  be  one  of  the  leading  symptoms.  There 
are  symptoms  of  intense  backaches,  pain  in  the  left  iliac  re- 
gion, across  the  abdomen  down  the  left  thigh,  in  the  bladder, 
uterus  and  prostate.  Reflex  symptoms  are  nausea  and  spas- 
modic cough.  The  character  of  the  fecal  evacuation  is  the  most 
positive  symptom.  The  physician  must  examine  the  feces  to 
determine  the  nature  of  the  trouble.  He  cannot  depend  solely 
on  the  description  given  by  the  patient.  If  the  discharges  con- 
tain a  great  deal  of  mucous  and  no  pus  there  will  be  a  con- 
gestion of  the  mucous  lining,  and  possibly  the  beginning  of  in- 
flammation. If  there  is  pus  and  blood  in  the  evacuations  you 
may  expect  the  presence  of  an  ulcer  somewhere  in  the  largo 
intestine,  and  if  an  ocular  examination  shows  the  rectum  to  be 
free  from  disease,  the  chances  are  the  ulcer  will  be  at  the  sig- 
moid.  If  there  is  no  history  of  specific  or  malignant  disease 
these  symptoms  will  be  of  great  help  in  the  diagnosis  of  con- 
gestion, inflammation  and  ulceration. 

In  the  treatment  of  diseases  at  the  rectum  and  sigmoid 
the  best  results  are  obtained  by  strict  asepsis,  and  the  use  of 
antiseptics  and  healing  applications.  You  must  not  only  de- 
stroy the  ptomains  and  toxines  that  cause  auto-infection,  but 
restore  the  functional  activity  and  remove  all  pathological  con- 
ditions of  the  colon. 

In  chronic  cases  of  long  standing  stringy  mucus  and  pus 
are  often  present  in  the  stools.  No  cure  can  be  accomplished 
before  the  lining  of  the  intestine  is  freed  from  the  unhealthy 
muco-pus.  We  should  begin  the  treatment  by  giving  an  aper- 
ient of  some  kind  to  thoroughly  wash  out  the  bowels  from 
above.  The  wash-out  should  be  followed  by  the  colon  douche. 
A  rectal  tube  with  syringe  attachment  will  answer.  The  rectal 
tube  should  be  carried  into  the  sigmoid  and  a  half  gallon  of 
hot  water  medicated  with  boracic  acid  pumped  into  the  colon. 
This  treatment  should  be  given  once  every  twenty-four  hours 
for  a  week ;  by  that  time  the  sigmoid  will  be  aseptic  and  ready 
for  a  healing  application.  Fluid  hydrastis  is  good.  One  or  two 
drams  in  two  ounces  of  hot  water  is  carried  into  the  flexure 
through  the  rectal  tube.  Have  the  injection  given  just  be- 
fore retiring,  and  if  the  fluid  can  be  retained  all  night  it  is 


OBIFIC1AL   SURGERY.  369 

better  for  the  patient.  Another  good  prescription,  used  in  the 
same  manner,  is  distilled  hammelis  and  fluid  calendula  equal 
parts.  While  using  these  prescriptions  have  the  colon  cleansed 
twice  a  week  with  hot  water  and  boracic  acid  to  keep  the  parts 
aseptic. 

A  mixture  of  almond  oil  1  pint,  iodoform  8  grains,  sub- 
nitrate  bismuth  1  dram  (Mathews),  is  both  soothing  and  heal- 
ing. Use  at  bedtime. 

Stricture  of  the  rectum  and  sigmoid  in  most  cases  is  the 
result  of  syphilis  or  cancer.  Some  relief  may  be  received  by 
the  use  of  bougies,  and  the  local  applications  just  mentioned. 
Sooner  or  later  surgical  procedure  will  be  called  for,  and  by 
the  aid  of  surgery  only  temporary  relief  can  be  expected.  If 
impaction  of  the  sigmoid  cannot  be  relieved  with  injections 
and  the  scoop,  laparotomy  may  be  necessary  for  the  removal 
of  the  impacted  mass.  While  treating  these  diseases  a  soft 
diet  may  be  prescribed — oysters,  milk,  broths,  soft-boiled  eggs, 
small  amount  of  bread,  and  a  very  little  of  meats.  For  in- 
ternal medication,  arsenicum,  ingluvin,  subnitrate  bismuth, 
salol,  the  mercuries,  the  iodides,  the  carbons  and  the  different 
forms  of  diastase  have  their  places  in  the  treatment  of  diseases 
of  the  rectum  and  sigmoid. 


CHAPTER  XL VII. 


SIGMOID  CATARRH  IN  WOMEN. 


CORA    SMITH    EATON,    M.    D. 


Last  September  at  Dr.  Pratt 's  clinic  in  orificial  surgery 
the  subject  of  chronic  constipation  and  its  cure  received  an 
extended  discussion.  It  is  the  gleanings  from  this  discussion 
with  my  own  modifications  which  constitute  the  line  of  treat- 
ment I  have  been  following  in  the  last  eight  months.  My  cases 
of  sigmoid  catarrh  have  numbered  about  twenty.  The  ma- 
jority of  these  were  suffering  from  constipation,  a  few  from 
chronic  diarrhea ;  in  other  words,  the  dry  catarrh  is  more  com- 


370  ORIFIGIAL    SURGERY. 

mon  than  the  moist  variety.  The  results  in  all  have  been  ex- 
cellent and  in  some  simply  phenomenal.  The  theory  of  the 
treatment  is  this: 

First.  To  cleanse  the  bowel  of  the  superficial  coat  of  mu- 
cus by  large  colon  flushings  at  home. 

Second.  By  a  medicated  irrigation  at  the  office,  into  which 
an  electric  current  is  turned  to  loosen  a  deeper  layer  of  mu- 
cus and  also  to  stimplate  the  paralyzed  muscular  coat  of  the 
bowel. 

Third.  After  this  double  cleansing  and  stimulation  has 
been  accomplished  to  inject  a  medicated  oil  as  high  as  possible 
into  the  bowel,  to  act  in  the  double  capacity  of  still  further 
loosening  the  crust  of  old  mucus  deposited  and  to  heal  the  dis- 
eased mucus  surface. 

Fourth.  To  assist  the  total  results  by  every  means  con- 
stitutional and  systemic,  as  internal  medicines  and  central 
faradization. 

Before  this  treatment  is  attempted  every  organic  trouble 
should  be  relieved,  such  as  lacerations,  pockets,  papillae,  ad- 
hesions to  clitoris,  etc.  Special  attention  should  be  given  to  the 
spine  to  make  sure  it  is  straight.  Some  of  these  cases  are  oc- 
casioned by  paralysis  of  the  intestinal  nerves  following  a  cur- 
vature. To  complete  the  cure  requires  from  one  to  six  months. 
The  treatment  should  be  given  every  second  day  at  first,  then 
every  third  or  seventh  day  as  the  case  progresses.  In  the  in- 
terval between  treatments  the  patient  should  each  day  take  a 
large  colon  flushing  to  wash  away  the  loosened  mucus  and  that 
which  has  been  forming  during  the  last  twenty-four  hours.  If 
the  patient  is  too  weak  to  endure  the  flushings  daily,  or  if 
there  is  a  daily  stool  without  them,  there  may  be  used  instead 
of  the  flushings  merely  four  ounces  of  sweet  oil,  medicated  or 
not,  injected  into  the  rectum  in  the  knee-chest  position.  This 
position  is  retained  until  the  oil  has  run  up  into  the  large 
bowel.  It  will  then  in  all  probability  be  held  until  the  bowel 
movement  takes  place,  unless  there  is  such  a  clogging  of  the 
sigmoid  with  mucus  that  nothing  can  pass  without  an  enema. 

When  the  patient  comes  to  the  office  she  is  supposed  to 
have  cleansed  the  bowel  with  from  four  to  twenty  quarts  of 


ORIFIC1AL    SURGERY.  371 

water,  taken  in  the  knee-chest  position  until  the  water  comes 
back  free  from  mucus.  She  is  put  upon  the  table  with  the 
Kelly  pad  under  her.  Cole's  sigmoid  irrigator  is  passed  into 
the  bowel  full  length  and  through  this  is  injected  from  a  foun- 
tain syringe  two  quarts  of  water  medicated  with  two  teaspoon- 
fuls  of  Kennedy's  White  Finns  Canadensis  and  two  teaspoon- 
fuls  of  salt.  Of  course  any  other  medications  can  be  used,  such 
as  hammelis,  hydrastis,  calendula,  etc. 

After  the  two  quarts  of  water  have  run  into  ihe  bowel, 
I  disconnect  the  syringe  tubing  from  the  Cole's  irrigator  and 
connect  the  irrigator  with  one  pole  of  the  battery.  The  other 
pole  is  placed  on  the  abdomen.  The  current  used  is  the  pri- 
mary farad ic  interrupted,  and  is  continued  for  ten  minutes. 
The  irrigator  is  then  withdrawn  and  the  patient  is  allowed  to 
pass  the  water  that  was  in  the  bowel,  much  of  which  will  pass 
from  the  bladder,  so  quickly  is  it  absorbed  into  the  circula- 
tion and  excreted  by  the  kidneys. 

We  have  had  a  few  cases  where  the  sigmoid  was  so  swollen 
and  coated  that  not  even  the  finger  could  enter,  and  the  irri- 
gator could  not  be  passed  till  treatment  had  relieved  this 
practical  stricture.  In  these  cases  we  fill  the  lower  bowel  with 
medicated  water  through  a  rectal  tube  instead  of  the  irrigator 
and  give  the  electricity  with  one  pad  under  the  lumbo-dorcal 
region  and  one  over  the  abdomen,  while  the  water  is  in  the 
bowel.  In  the  constipation  cases  the  large  flakes  and  crusts  of 
hardened  mucus  which  come  away  under  treatment  are  start- 
ling both  as  to  thickness  and  quantity.  It  is  not  uncommon 
for  a  patient  to  pass  after  the  electric  treatment,  a  double 
handful  of  mucus  looking  like  shredded  codfish.  Sometimes 
flecks  of  blood  show  where  scabs  formed  over  ulcers.  This  mu- 
cus and  blood  gradually  decreases  until  only  fresh  mucus,  like 
uncooked  white  of  egg  appears,  such  as  is  the  normal  intes- 
tinal lubricant. 

After  the  water  has  come  away  the  patient  is  put  on  the 
table  again  in  the  knee-chest  position  and  a  long  colon  tube  is 
passed  full  length ;  through  this  is  injected  by  a  hard  rubber 
piston  syringe  four  ounces  of  oil  medicated  with  oil  of  tar, 


372  ORIFIG1AL    SURGERY. 

eucalyptus  or  hydrastis.  The  tube  is  cautiously  withdrawn  and 
the  patient  remains  in  the  knee-chest  position  for  ten  minutes 
to  help  the  oil  stay  where  it  is  needed. 

We  have  lately  found  we  get  almost  if  not  quite  as  good 
results,  with  far  less  trouble  to  ourselves  and  less  discomfort 
to  the  patient,  by  giving  the  oil  simply  into  the  rectum  and 
having  the  position  retained  for  ten  or  fifteen  minutes.  Some- 
times it  is  a  terrible  trial  to  pass  the  tube  as  it  kinks  in  the 
sigmoid  or  else  hurts  the  patient  unconscionably.  After  the  pa- 
tient has  passed  the  water  and  before  we  give  the  oil  we  fre- 
quently have  her  lie  on  a  flat  electrode  and  take  a  spinal  sec- 
ondary faradic  cupping.  It  is  a  very  fine  stimulus  to  the  bow- 
el nerves  which  are  given  off  from  the  spine.  Besides  that, 
it  starts  up  contractions  in  the  bowel  sufficient  to  help  expel 
any  water  which  may  remain.  In  the  preparation  which  they 
make  at  home,  we  have  them  medicate  the  last  two  quarts 
with  some  of  the  medicines  I  have  named  as  using  at  the  of- 
fice. The  remedies  used  by  mouth  are  most  frequent  hamam. 
Ix,  napthalin  2x,  sabad.  3x,  and  a  combination  tablet  consisting 
of  pepsin,  nux  vom.  and  carbo  veg.  to  be  taken  before  and 
after  meals. 

This  treatment  has  served  to  clear  up  for  us  so  many  ob- 
scure cases  that  we  no  longer  grudge  the  time  and  effort  re- 
quired to  follow  it. 


CHAPTER  XL VIII. 


"THE  SIGMOID." 


G.   E.   COGSWELL,   M.   D. 


That  we  live  by  reason  of  the  sympathetic  nerve  is  a  fact 
so  well  established  that  to  attempt  to  prove  it  is  entirely  un- 
necessary. 

Any  irritation  of  this  nerve  whereby  it  is  weakened  and 
its  power  wasted,  is  sufficient  to  account  for  many,  if  not 
most,  of  the  so-called  chronic  ailments,  by  whatever  name 


ORIFICIAL   SURGERY.  373 

known.  While  this  is  true,  it  is  not  always  easy  to  tell  the  pre- 
cise spot  where  this  irritation  is  located,  nor  having  found  the 
place,  is  it  always  easy  to  remove  it.  Again,  when  there  has 
been  all-around  work  done,  we  find  there  is  a  slow  reaction  and 
reproduction  of  the  local  irritation  which  calls  for  repeated 
removals,  ere  the  patient  has  fully  recovered.  From  this  it 
would  seem  as  if  there  were  some  irritation  other  than  what 
appeared  on  the  surface,  and  some  other  treatment  called  for 
before  the  cure  can  be  made  permanent;  some  irritation  of  an 
obscure  kind  that  at  first  escaped  notice,  but  still  persists  in 
keeping  up  the  nerve  waste  so  that  its  functions  are  interfered 
with,  thus  continuing  the  reflex  condition. 

One  of  the  particular  locations  for  these  obscure  irrita- 
tions is  the  sigmoid  flexure  of  the  bowel.  For  the  reason  that 
it  lies  so  high  up  in  the  pelvis,  and  so  entirely  behind  the  blad- 
der and  uterus,  having  but  few  symptoms  peculiarly  its  own, 
but  usually  manifesting  its  discomfiture  by  reflex  symptoms, 
it  is  often  overlooked  and  neglected,  and  the  trouble,  if  left 
to  itself,  may  compel  the  patient  to  succumb,  the  victim  of  our 
neglect. 

The  sigmoid  flexure  of  the  bowTel  is  the  narrowest  part  of 
the  descending  colon.  It  is  situated  in  the  left  iliac  fossa,  com- 
mencing from  the  termination  of  the  descending  colon  at  the 
margin  of  the  crest  of  the  ileum  and  ending  in  the  rectum  op- 
posite the  left  sacroiliac  symphysis.  It  curves  in  the  first  place 
inward  across  the  psoas  muscle;  it  then  descends  vertically 
along  the  left  wall  of  the  pelvis,  and  finally  again  passes  in- 
ward to  the  left  sacro-iliac  joint  where  it  becomes  the  rectum. 
It  is  retained  in  position  by  the  loose  folds  of  the  peritoneum% 
the  sigmoid-mesocolon ;  it  is  in  relation  in  front  with  the  small 
intestines  and  the  abdominal  parietes. 

Treves  defines  the  sigmoid  flexure  as  that  portion  of  the 
large  bowel  from  the  psoas  muscle  to  the  third  sacral  vertebra. 
He  includes  therefore  and  properly  in  the  sigmoid  flexure  the 
first  part  of  the  rectum  as  it  is  usually  denominated;  it  lies 
not  in  the  left  ilias  fossa  but  in  the  pelvis.  It  is  not  S-shaped 
but  is  a  large  loop  171^  inches  long  and  shaped  more  like  the 
Greek  letter  Omega,  or  an  inverted  U,  the  top  of  the  loop 


374  ORIFIG1AL    SUEGERY. 

sometimes  even  touching  the  right  side  of  the  pelvis.  Such  in 
brief  is  the  description  we  have  in  Gray's  Anatomy  of  that 
portion  of  the  alimentary  canal  that  plays  so  important  a  part 
in  the  treatment  of  chronic  cases  by  orificial  methods.  To  me 
the  sigmoid  is  the  door  through  which  success  has  been  reached, 
and  without  which  failure  must  have  been  met. 

A  fact  to  remember  in  connection  with  this  part  of  the  in- 
testinal tract  is  its  location  and  the  part  it  is  called  upon  to 
do  in  maintaining  the  body  in  a  state  of  health. 

Where  the  sigmoid  ends  and  the  rectum  begins  is  an  ac- 
cumulation of  muscular  fibers  known  as  the  sphincter  of 
0  'Bierne,  which  narrows  the  intestine,  making  it  almost  the  in- 
ner door  to  the  rectum,  and  preventing  the  escape  of  the  fecal 
matter  into  the  lower  bowel  until  the  mass  shall  have  ac- 
cumulated in  the  colon  in  sufficient  quantities,  that  by  passing, 
the  outer  door  or  external  sphincter,  it  shall,  by  dilation, 
flush  the  entire  capillary  circulation  of  the  whole  body. 

It  is,  therefore,  the  repository,  so  to  speak,  of  the  waste 
products  of  the  food,  and  ofttimes  becomes  very  tolerant  of 
these  accumulations,  as  well  as  diseased  conditions  arising 
therefrom.  It  is  supplied  with  nerves  from  the  same  ganglia 
as  the  uterus  and  prostate,  the  rectum  and  bladder,  and  is  in 
so  close  relation  to  these  parts  that  it  is  very  easy  to  under- 
stand how  irritation  at  these  points  may  produce  trouble  at 
the  sigmoid,  which,  having  but  few  sensory  nerves,  can  only 
express  its  disconfiture  in  the  way  of  perverted  function  01*  re- 
flex condition. 

Because  of  the  obscurity  of  the  part  and  the  absence  of 
pain,  it  is  too  often  overlooked  in  diagnosing  a  diseased  condi- 
tion ;  but  the  close  relations  existing  between  the  sigmoid  and 
stomach,  the  lungs  and  thyroid  gland,  as  well  as  the  uterus, 
bladder  and  rectum,  give  it  an  important  place  in  perfecting 
our  diagnosis  of  any  obstinate  chronic  condition,  and  they  will 
not  become  chronic  if  not  obstinate. 

In  the  normal  condition  the  process  of  digestion  and  as- 
similation, as  well  as  the  elimination  of  the  waste  products  of 
the  food  and  tissue,  is  carried  on  without  our  being  conscious 
of  it,  so  that  we  find  but  few  nerves  of  sensation  after  we  leave 


OEIFIO1AL   SURGERY.  375 

the  surface;  and  what  is  true  in  the  general  sense  is  also  true 
at  the  sigmoid  flexure.  Hence,  pain  becomes  a  very  unreliable 
symptom  from  which  to  tell  where  the  trouble  is;  in  fact,  a 
patient's  sensations  are  of  but  little  account  in  making  a  di- 
agnosis, or  locating  the  irritation  that  is  responsible  for  the 
nerve  waste  that  has  resulted  in  the  impairment  of  the  health. 

It  is  to  the  local  irritation  and  to  the  objective  symptoms 
that  we  must  look  for  the  causes  that  are  active  in  keeping  up 
the  irritation.  We  start  with  the  thought,  if  one  is  sick  some- 
thing is  the  matter,  or  rather,  there  must  be  a  cause;  that 
cause  is  nerve  waste  which  may  be  at  the  sigmoid  as  well  as 
at  the  orifices  of  the  body. 

Any  of  the  more  serious  chronic  troubles,  such  as  con- 
sumption, paralysis,  rheumatism,  or  the  much  abused  com- 
plaint, indigestion,  may  all  have  their  start  at  the  sigmoid,  and 
will  remain  until  that  part  of  the  intestinal  tract  is  freed  from 
its  irritation  and  the  contraction  of  its  sphincter. 

We  may  clear  the  rectum  of  its  pockets  and  papillae,  hem- 
orrhoids and  fissures,  or  whatever  form  of  irritation  found 
there;  we  may  remove  from  the  sexual  system  everything 
that  causes  nerve  waste;  we  may  loosen  the  hood  of  the  cli- 
toris, and  liberate  it  from  its  long  captivity,  according  to  the 
most  approved  orificial  method;  we  may  clip  the  frenum,  en- 
large the  meatus,  dilate  the  urethra  and  circumcise  the  fore- 
skin, and  still  find  that  the  same  trouble  exists  and  is  doing 
business  at  the  old  stand,  as  one  important  part,  the  sigmoid, 
has  been  overlooked. 

This  is  but  following  out  the  orificial  idea  that  all  of  the 
orifices  must  be  free  from  irritation  and  easily  dilatable,  for 
the  sphincter  of  O'Beirne  is  but  the  sentinel  guarding  the  out- 
let of  the  sigmoid  and  is  subject  to  the  same  constriction  as 
the  other  sphincter,  and  must  be  treated  in  much  the  same 
way,  by  thorough  dilatation  and  the  removal  of  the  offending 
portion. 

That  we  can  have  irritation  here,  and  not  at  the  lower 
opening  of  the  bowel,  as  a  primary  condition,  is  a  question ; 
but  that  we  do  have  irritations  at  the  sigmoid  in  connection 
with  those  at  the  other  orifices,  and  that  they  can  continue  af- 


376  ORIFICIAL    SURGERY. 

ter  the  other  irritations  have  been  removed,  is  no  longer  a 
question,  but  an  established  fact,  and  one  that  we  must  take 
into  consideration  in  those  obstinate  cases  that  manifest  so 
strong  a  tendency  to  return  after  they  have  once  been  ordered 
off  the  premises. 

We  must  still  carry  out  the  orificial  thought:  all  nerve 
waste  must  be  stopped,  so  that  all  the  sympathetic  nerve  power 
shall  be  used  in  carrying  on  the  nutrition  of  the  body,  and  not 
be  spent  in  building  up  a  diseased  condition. 

The  means  suggested  for  the  treatment  of  the  sigmoid  have 
been  many,  and  it  seems  to  me  that  we  have  yet  to  find  the 
ideal  one.  Many  times  it  is  difficult  to  reach  the  point  of  ir- 
ritation owing  to  the  constriction,  which  must  first  be  dilated ; 
again,  a  too  redundant  tissue  and  a  relaxed  condition  of  the 
mucous  membrane  is  an  obstacle  in  the  way;  however,  in  re- 
peated and  persistent  effort  it  can  usually  be  accomplished. 

The  conditions  here,  unlike  the  lower  orifices,  cannot  al- 
ways be  removed  at  one  sitting,  but  must  be  repeated  until  by 
reaction  the  parts  have  been  brought  to  a  normal  condition. 

In  those  cases  that  do  not  react  well  after  an  operation, 
or  fail  to  manifest  the  improvement  expected,  you  will  prob- 
ably have  some  trouble  at  this  point;  it  is  this  class  of  cases 
that  I  shall  offer  as  an  excuse  for  this  paper. 

It  is  not  my  purpose  to  give  in  detail  the  cases  only  so 
far  as  the  treatment  of  the  sigmoid  is  concerned,  but  I  wish 
to  state  at  the  beginning  that  in  most  of  the  cases  that  have 
trouble  at  the  sigmoid  you  will  find  more  or  less  irritation  at 
the  lower  orifices,  which  precedes  the  trouble  higher  up  in 
the  bowel;  hence  the  preliminary  orificial  work  is  necessary 
to  obtain  the  best  results.  On  the  other  hand,  there  are  many 
cases  that  have  received  all-round  orificial  work,  the  results 
of  which  have  not  been  satisfactory,  and  in  such  cases  the 
fault  many  times  will  lie  at  the  sigmoid  flexure,  which  will 
need  special  treatment  for  complete  success. 

The  following  will  illustrate  some  of  the  means  used  in 
the  successful  treatment  of  those  cases  which  otherwise  would 
have  been  failures. 


ORIFIC1AL   SURGEBY.  377 

CASE  1. — Mrs.  M.,  aged  65.  Paralysis  of  the  lower  ex- 
tremeties,  torpor  of  the  digestion,  laceration  of  the  cervix, 
and  hemorrhoids;  seemingly  a  typical  case  for  orificial  work. 
After  the  operation,  which  afforded  some  relief,  the  bowels 
were  still  inactive,  with  a  tendency  to  dropsy.  Dilatation, 
colon  flushing,  and  careful  prescribing  alike  were  ineffectual; 
a  thorough  dilatation  of  the  sigmoid,  with  an  injection  of  lin- 
seed oil  and  hydrastis  for  a  few  weeks,  effected  a  cure. 

CASE  2. — Mrs.  P.,  aged  56.  Epilepsy ;  all-round  work  gave 
but  little  benefit,  but  the  continued  use  for  two  months,  of  the 
large  rectal  bougies  with  the  injection  of  oil  and  cascara,  the 
wool  tampon  medicated  with  boro-glyceride  and  oil,  introduced 
in  the  sigmoid,  massage  over  the  abdomen  and  daily  anoint- 
ing with  olive  oil  has  given  the  most  help ;  in  this  case,  when- 
ever there  seemed  to  be  more  sluggishness  of  the  bowels,  there 
would  be  an  attack,  but  the  use  of  the  long  rectal  tube  with 
oil  would  stop  the  trouble. 

CASE  3. — Mr.  B.,  aged  40.  A  supposed  case  of  cancer  of 
the  stomach.  The  local  trouble  was  rectal  fistula,  which  was 
operated  on  about  a  year  prior  to  my  seeing  the  case.  This 
operation  gave  relief  for  about  three  months,  when  all  the  old 
symptoms  returned  with  greater  force.  At  the  examination 
there  was  but  little  local  trouble.  Thorough  dilatation,  mas- 
sage, electricity  and  colon  flushing,  as  well  as  smoothing  up 
of  the  lower  orfices,  gave  no  relief.  A  Cole's  irrigator,  passed 
with  difficulty,  brought  away  a  quantity  of  mucus,  and  the 
continued  use  of  the  irrigator,  followed  with  the  larger  rectal 
tube  and  medicated  oil  for  a  few  weeks,  brought  on  reaction, 
and  the  patient  has  recovered  his  normal  health.  This  was  a 
case  that  had  been  given  much  morphine,  and  the  trouble  at 
the  sigmoid  was  largely  due  to  this  fact. 

It  has  been  my  observation  that  in  morphine  subjects 
there  will  be  more  or  less  trouble  at  this  point,  owing  to  the 
fact  that  the  constipation  due  to  the  drug  will  many  times 
cause  the  irritation  and  constriction  of  the  sigmoid,  ami  to 
thoroughly  overcome  the  habit  it  must  receive  the  attention 
it  needs.  In  this  case  we  found  that  as  the  waste  of  the  bowels 
passed  down  to  this  point  there  would  be  the  uneasiness  felt 


378  ORIFIC1AL    SURGERY. 

at  the  stomach  and  the  right  side  of  the  abdomen,  assimilating 
almost  an  appendicitis,  but  every  time  after  using  the  large 
rectal  tube  and  relieving  the  sigmoid,  there  would  be  a  relief 
from  all  these  other  symptoms. 

CASE  4. — Mrs.  P.,  aged  58.  After  thorough  all-round  work 
for  laceration,  adherent  hood,  pus  pockets  around  the  meatus, 
piles,  pockets  and  papillae  of  the  rectum,  still  continued  to  have 
high  fever,  cough,  night  sweats,  feet  bloated,  loss  of  appetite, 
and  at  times  diarrhea  and  constipation;  it  was  thought  to  be 
a  clear  case  of  tuberculosis.  For  several  months  after  the  op- 
eration these  symptoms  continued;  the  cough,  which  was  spas- 
modic, now  became  constant,  and  could  only  be  relieved  by  a 
rectal  suppository  of  cocaine,  boracic  acid  and  cocoa  butter; 
massage,  electricity,  baths,  and  the  combined  prescribing  of 
several  physicians,  the  patient  gradually  sinking  under  the 
disease.  There  was  no  soreness  over  the  lungs,  no  cavity,  but 
little  expectoration,  complete  loss  of  appetite,  great  dryness 
of  the  mucous  surfaces,  and  but  little  thirst.  The  bowels  were 
flat,  and  percussion  and  palpitation  gave  no  soreness  nor  any 
indication  of  trouble.  The  sphincters  were  dilated  without 
any  reaction  following;  the  patient  very  anemic,  but  the  high 
temperature  continued.  On  passing  the  Cole's  irrigator,  and 
throwing  up  four  ounces  of  cottonseed  oil  and  glycerine,  there 
was  nearly  a  pint  of  pus  brought  away.  The  colon  flushing  had 
been  used  faithfully  several  times  prior,  which  failed  to  move 
the  bowels.  After  the  discharge  of  pus  the  fever  seemed  to 
abate.  I  now  attempted  to  pass  the  large  rectal  tube  into  the 
sigmoid,  and  I  wrish  to  state  that  at  the  time  of  the  operation, 
when  the  patient  was  under  an  anesthetic,  there  was  little  or 
no  trouble  in  dilating  the  sigmoid,  both  with  a  Pratt  sigmoid 
speculum  and  the  large  rectal  tube,  but  now  I  found  a  great 
deal  of  trouble  in  getting  the  large  tube  through  the  sphinc- 
ter of  O'Beirne.  It  was  accomplished  in  the  following  man- 
ner: 

First,  by  throwing  into  the  rectum  about  two  ounces  of 
oil,  then  introducing  the  tube  as  far  as  it  would  go,  taking 
care  that  the  end  entered  the  lower  curve,  then  by  adding  a 
little  more  oil,  thus  forcing  the  bowel  open  just  ahead  of  the 


ORIFIC1AL   SURGERY.  379 

tube,  and  so  alternating  by  using  the  oil  and  forcing  the  tube 
up,  we  finally  succeeded  in  passing  the  tube  into  the  sigmoid, 
then  using  from  four  to  six  ounces  of  oil  and  phytolacca.  I 
use  the  oil  instead  of  the  water  because  it  gives  better  results 
and  the  tube  passes  more  easily.  The  mucus  in  this  case  was 
almost  a  cast  of  the  bowels,  somewhat  like  the  membrane  from 
a  diphtheritic  throat.  This  was  continued  twice  or  three 
times  a  week,  as  the  patient  could  stand  it,  for  four  or  five 
weeks,  with  the  result  of  lessening  the  fever,  increasing  the 
appetite  and  emeliorating  the  cough.  One  fact  in  the  case 
was,  almost  every  time  after  using  the  large  tube  there  would 
be  a  hoarseness  not  unlike  that  consequent  on  a  recent  cold; 
it  would  last  from  twelve  to  twenty-four  hours,  when  it  would 
subside  without  any  treatment.  The  case  has  gone  on  to  com- 
plete recovery,  and  I  believe  but  for  the  persistent  use  of  the 
rectal  tube  introduced  into  the  sigmoid  it  must  have  been  re- 
corded as  a  failure. 

Now  a  word  as  to  the  medicines  used  in  the  sigmoid.  I 
have  used  sweet  oil,  linseed  oil,  cotton-seed  oil  and  lard, 
melted  vaseline  and  glycerine ;  my  preference  without  special 
indication  is  for  cotton-seed  oil.  To  this  is  added  such  reme- 
dies as  hydrastis,  phytolacca,  calendula,  hamamelis,  cascara, 
sulphate  of  magnesia,  boracic  acid,  glycerine  and  peroxide  of 
hydrogen.  In  one  case  of  hemorrhage  I  found  great  benefit 
from  cotton-seed  oil  used  through  a  Cole's  irrigator. 

In  closing,  just  a  word  about  the  colon  douche.  It  has 
been  my  experience  that  the  too  frequent  douching  has  rather 
increased  the  constipation  than  lessened  it ;  for  a  few  times 
much  good  may  be  done  by  using  from  three  to  five  quarts  of 
salt  water,  forcing  it  well  up  into  the  colon;  but  this  should 
not  be  used  too  frequently  or  continued  too  long  or  it  will 
cause  a  loss  of  tone  instead  of  increasing  peristalsis.  Neither 
should  the  water  be  too  hot  unless  it  be  a  case  of  diarrhea, 
when  the  hotter  the  water  the  better,  up  to  the  point  of  tol- 
eration. In  obstinate  constipation  with  extreme  sluggishness 
and  loss  of  peristaltic  action,  the  water  may  be  used  almost 
cold  but  should  not  be  used  oftener  than  once  a  week  or  ten 


380  ORIPIC1AL   SURGERY. 

days.     Its  effect  may  be  increased  by  adding  a  small  cup  of 
common  salt  and  two  or  three  ounces  of  glycerine. 

In  the  diarrhea  of  typhoid  fever  and  cholera  infantum 
much  good  may  be  done  by  the  use  of  the  colon  douche  with 
hot  water  and  milk,  but  the  quantity  must  be  as  large  as  can 
be  borne  and  not  used  too  often. 

CHAPTER  XLIX. 


NON-MALIGNANT  DISEASES  OF  THE  UPPER  RECTAL 
POUCH  AND  SIGMOID  FLEXURE,  AND  AN  IM- 
PROVED METHOD  OF  TREATMENT. 


E.    Z.    COLE.    M.    D. 


Of  late  years  much  has  been  written  upon  diseases  of  the 
rectum  and  the  lower  orifices  of  the  body,  but  little  has  been 
said  of  the  non-malignant  diseases  of  the  upper  rectal  pouch 
and  the  sigmoid  flexure,  and  their  treatment.  I  mention  the 
two  because  it  is  almost  impossible  to  separate  them,  they  be- 
ing generously  supplied  with  sympathetic  nerve  tissue  and 
being  a  continuation  of  the  same  mucous  surface;  and  as  a 
rule  when  we  find  a  diseased  condition  of  the  one,  we  will  find 
the  other  affected.  And  many  of  the  local  and  reflex  symp- 
toms are  similar. 

In  my  own  experience  in  orificial  work,  no  class  of  cases 
has  given  me  so  much  trouble  as  those  suffering  from  obscure 
diseases  of  the  sigmoid — I  found  them  hard  to  make  out  and 
still  harder  to  treat.  It  took  me  some  little  time  to  realize  the 
fact  that  a  diseased  condition  of  the  lower  bowel  is  almost  in- 
variably accompanied  by  trouble  higher  up.  If  the  one  is  treat- 
ed and  the  other  overlooked  your  patient  will  not  make  the 
progress  that  you  desire. 

The  first  one  to  call  my  attention  to  this  fact  was  the 
late  Dr.  Geo.  A.  Hall.  It  was  my  privilege  to  receive  much 
private  instruction  from  him  upon  this  subject,  and  also  to 
attend  his  lectures  upon  rectal  surgery.  Many  of  you  have 


ORIFIC1AL   SURGERY.  381 

doubtless  read  his  lecture  in  the  February  number  of  the 
Journal  of  Orificial  Surgery,  and  will  remember  his  question : 
"Why  do  not  all  of  our  patients  receive  like  benefit  from  ori- 
ficial  treatment?"  And  his  answer  to  the  same:  "It  is  due 
to  the  fact  that  the  pathological  changes  involving  the  rectum 
and  sigmoid  have  been  overlooked." 

His  descriptive  symptoms  of  proctitis  are  so  character- 
istic of  the  local  and  reflex  symptoms  that  I  have  observed  in 
some  sigmoidal  troubles,  that  I  cannot  do  better  than  to  give 
them  here.  He  says:  "The  patient  will  not  as  a  rule  complain 
of  pain  in  the  rectal  district,  but  will  complain  of  pain  in  the 
back  of  the  head  and  in  the  dorsal  region,  pain  in  the  occiput 
extending  around  to  the  forehead,  attacks  of  dizziness,  verti- 
go, pain  in  the  lumbar  and  sacral  region  extending  down  the 
thighs,  a  sense  of  numbness  and  disability  of  the  limbs,  consti- 
pation of  long  standing,  irregular  action  of  the  heart,  violent 
palpitation  awaking  him  from  sleep,  dyspepsia  and  feeble  di- 
gestion, asthma  or  harassing  cough,  and  pain  in  the  inguinal 
region,  in  the  female  often  mistaken  for  ovarian  irritation. 
The  once  amiable  disposition  has  become  perverted,  the  pa- 
tient feels  irritable,  peevish,  despondent,  apprehensive  and  is 
usually  more  or  less  emaciated.  Now,  you  may  have  one  or 
more  of  the  symptoms  which  I  have  described,  in  any  given 
case.  There  may  exist  only  one ;  that  may  be  simply  nausea 
and  vomiting  when  first  rising  in  the  morning;  or  there  may 
be  simply  an  unpleasant  feeling  in  the  head,  with  loss  of 
memory. ' ' 

I  will  add  that  if  the  trouble  be  localized  in  the  sigmoid, 
there  will  frequently  be  colicky  pains  in  the  stomach  and 
bowels,  a  great  amount  of  flatus,  constipation  or  diarrhoea,  and 
straining  at  stool ;  but  the  greatest  pain  is  as  a  rule  just  be- 
fore going  to  stool,  at  the  moment  the  feces  pass  through  the 
sigmoid  flexure. 

In  the  female  the  mucous  surface  is  sometimes  so  sensi- 
tive right  back  of  the  uterus  as  to  give  rise  to  the  belief  that 
the  pain  is  in  the  uterus  and  ovary,  and  these  organs  are  con- 
sequently subjected  to  an  undue  amount  of  unnecessary  at- 
tention. 


382  ORIFIG1AL    SURGERY. 

I  am  firmly  convinced  that  the  primary  cause  of  inflamma- 
tion of  the  flexure  is  constipation.  Considering  the  physiology 
of  the  act  of  defecation,  O'Beirne  says,  "If  the  calls  of  nature 
are  not  heeded,  the  fecal  mass  is  lifted  back  into  the  sigmoid 
flexure  and  there  remains  until  the  next  effort  is  made."  Dur- 
ing this  time,  of  course  the  watery  constituent  of  the  mass  is 
reabsorbed  and  the  remainder  is  left  in  a  hardened  condition. 
What  could  be  the  source  of  greater  mechanical  irritation  than 
this? 

Is  it  any  wonder  then  that  a  congestion,  an  inflammation 
and  lastly  an  ulceration  could  occur? 

When  we  take  into  consideration  the  fact  that  putrefact- 
ive changes  must  have  been  going  on  while  this  mass  was  re- 
tained in  the  sigmoid,  we  can  readily  understand  that  septic 
organisms  must  pass  into  the  circulation. 

Dr.  Mathews  thinks  the  dark  color,  emaciation,  sweats, 
etc.,  that  are  frequently  observed  in  persons  suffering  from  the 
constipated  habit,  are  due  to  a  species  of  sepsis  or  so-called 
blood-poison.  Hence  the  importance  of  keeping  the  sigmoid 
clear,  whatever  the  condition  of  your  patient  may  be  other- 
wise. 

Always  investigate  the  upper  part  of  the  rectal  pouch  and 
the  sigmoid  when  you  are  examining  and  doing  orificial  work 
for  a  case.  You  will  never  regret  the  extra  pains  taken,  and 
will,  in  many  cases,  be  gratified  with  the  results  of  this  plan 
of  procedure. 

The  trouble  that  I  experienced  in  carrying  out  Dr.  Hall's 
plan  of  treatment,  was  that  there  was  no  proper  instrument  for 
reaching  and  treating  the  sigmoid. 

He  used  his  long  double  curved  forceps,  holding  a  pledget 
of  cotton  saturated  with  carbolated  or  borated  glycerine,  etc., 
to  swab  out  and  medicate  this  region.  But  this  was  a  very  dif- 
ficult and  imperfect  way  of  doing  the  work. 

One  objection  to  this  method  of  treating  was  that  patients 
could  not  carry  it  on  by  themselves,  as  it  required  an  ex- 
perienced operator  to  use  the  forceps  safely. 

I  felt  that  if  some  method  could  be  devised  by  which  the 
sigmoid  could  be  reached  easily  and  safely,  and  by  which 


ORIFICIAL    SURGERY.  383 

fluids  could  be  used  instead  of  swabbing  with  pledgets  of  cot- 
ton, then  patients  could  carry  out  the  plan  of  treatment  at 
home. 

Another  objection  that  I  wished  to  overcome  was,  that  in 
the  majority  of  the  cases  we  were  swabbing  out  a  sigmoid 
loaded  with  fecal  matter,  mucus,  etc.,  which,  of  course,  pre- 
vented thorough  work. 

In  my  efforts  to  overcome  these  difficulties,  I  devised  this 
little  instrument  which  I  call  a  Sigmoid  Irrigator.  It  is  a  hol- 
low tube,  taking  the  natural  curves  of  the  lower  bowel  and 
has  a  bulbous  end  which  is  perforated  for  the  passage  of 
fluids.  This  little  device  has  given  me  greater  satisfaction  and 
has  yielded  better  results  than  any  one  instrument  I  have  ever 
possessed,  because  it  has  made  the  sigmoid  as  accessible  to 
diagnosis  and  treatment  as  the  rectum. 

With  this  all  accumulations  can  be  thoroughly  washed 
out  of  the  sigmoid  and  descending  colon  before  any  medica- 
tion is  used.  After  a  thorough  washing  out,  from  one  to  four 
ounces  of  whatever  medication  you  wish  can  usually  be  re- 
tained in  the  sigmoid  from  a  half  an  hour  to  several  hours.  In 
the  congestive,  inflammatory,  and  catarrhal  conditions,  or 
where  they  have  gone  on  to  ulceration — discharging  daily  large 
quantities  of  viscid  mucus,  sometimes  even  pus — I  find  that  a 
thorough  use  of  three  or  four  quarts  of  very  hot  water  fol- 
lowed by  the  proper  medication  will  speedily  clear  up  these 
conditions. 

For  washing  out  the  sigmoid  always  use  boiled  water,  but 
it  is  best  never  to  use  water  alone.  A  little  salt,  oil,  glycerine, 
milk  or  starch  can  be  put  in  the  water,  any  one  of  which  will 
render  it  less  irritating. 

I  have  sometimes  found  that  the  indicated  remedy  may  be 
used  advantageously  as  a  medication  in  the  sigmoid;  but  we 
frequently  have  to  perscribe  for  the  pathological  conditions 
which  we  know  to  exist  and  not  for  symptoms  alone,  and  I 
have  found  the  following  useful  in  these  conditions,  carbolated 
or  borated  glycerine  or  oil. 

One  ounce  fluid  hydrastis  to  one  pint  of  olive  or  almond 
oil.  Solution  of  bismuth  and  hydrastis,  hammelis,  pinus  can- 


384  ORIPIG1AL    SURGERY. 

adensis,  listerine,  tar  water,  all  in  about  the   same  propor- 
tions will  be  found  good  remedies. 
There  are  also  such  remedies  as: 

Tannic  acid  5  to  10  gr.  to  oz. 

Sulphate  zinc   5  gr.  to  oz. 

Eucalyptus  oil   5  gtts.  to  oz. 

lodoform  or  Boracic  acid  5  to  10  gr.  to  oz. 
These  can  be  used  in  olive  oil,  glycerine  or  water,  ac- 
cording to  the  nature  of  the  medicament,  and  from  one  to  four 
fluid  ounces  can  be  retained  in  the  sigmoid.  The  treatment 
should  be  made  every  other  day,  but  later  every  third  day. 
Do  not  expect  good  results  from  any  treatment  unless  the  sig- 
moid has  been  thoroughly  washed  out  before  it  is  medicated. 

For  carrying  out  Dr.  Terry's  plan  of  treating  appendi- 
citis with  oil,  you  will  see  that  this  instrument  fulfills  every 
requirement.  It  places  the  oil  in  the  ilio-caecal  region  quickly 
and  safely,  and  would,  I  believe  if  used  in  time,  render  sur- 
gical interference  unnecessary  in  many  cases. 


SECTION  VI. 


The  Male 
Sexual  Organs, 


OBIFIG1AL    SURGERY.  387 


CHAPTER  L. 


SOME  POINTS  CONCERNING  THE   ANATOMY  AND 
PHYSIOLOGY  OF  THE  MALE  SEXUAL  ORGANS. 


E.   H.   PRATT,   M.   D. 


A  foreskin  of  proper  length  reaches  no  farther  than  the 
point  of  the  glans  penis,  leaving  this  part  continually  exposed. 
Upon  retraction  it  exercises  no  compression  whatever  upon  the 
glans,  and  when  completely  retracted  does  not  in  the  slightest 
degree  constrict  the  penis.  A  normal  frgenum  is  of  such 
length  that  when  the  foreskin  is  forcibly  retracted  it  does  not 
manifest  even  the  slightest  tendency  to  depress  the  point  of 
the  glans  penis. 

A  normal  meatus  urinarius  is  readily  dilatable  to  the  full 
calibre  of  the  urethra. 

The  color  of  the  apex  of  the  glans  and  the  membrane 
lining  the  meatus  is  an  index  of  the  condition  of  the  prostatic 
inch,  as  the  extremeties  of  any  canal  are  so  sympathetically 
associated  as  to  flush  and  pale  simultaneously.  A  bleached, 
pinched,  anaemic  condition  of  the  point  of  the  penis  means 
atropy  of  the  prostate. 

A  dark  red,  patulous  meatus  urinarius  indicates  prostatic 
congestion  of  the  passive  variety.  A  bright  red,  swollen 
meatus  means  an  acutely  congested  and  irritable  prostate.  A 
dark  red,  swollen  and  patulous  meatus  means  prostatic  hpyer- 
tropy. 

A  physician  who  is  capable  of  judging  of  the  condition 
of  the  stomach  and  liver  from  the  appearance  of  the  tongue, 
is  also  capable,  after  a  little  experience  and  observation,  of 
diagnosing  prostatic  conditions  from  the  appearance  of  the 
orifice  of  the  urethra. 

A  normal  prostate  gland  resembles  in  size  and  form  a 
horse  chestnut,  and  its  outlines  can  be  distinctly  felt  through 
the  rectum.  It  should  be  firm  in  texture,  and  should  present 
a  well-defined  groove  upon  its  under  surface,  dividing  it  into 


388  OEIFIC1AL    SURGERY. 

two  well  marked  lateral  lobes.  The  urethra  passes  through 
the  gland,  and  this  portion  of  it  is  about  an  inch  or  an  inch  and 
a  quarter  in  length. 

The  prostatic  gland  in  the  male  corresponds  to  the  uterus 
in  the  female,  and  is  supplied  by  the  corresponding  pencil  of 


TAKEN  FROM  WEISSE'S  ANATOMY 

sympathetic  nerve  fibres.  Therefore,  when  in  a  pathological 
state,  it  is  capable  of  instituting  all  the  reflex  disturbances 
and  symptoms  in  the  male  which  uterine  pathology  can  induce 
in  the  female. 

Functional  derangement  of  the  stomach,  pain  in  the  top  of 
the  head,  asthma,  paralysis,  acne,  nervousness,  spinal  irrita- 
tion, etc.,  can  all  be  induced  by  the  morbid  condition  of  the 
prostate  gland,  just  as  a  similar  state  of  symptoms  in  the  gen- 


ORIFIG1AL   SURGERY. 


389 


tier  sex  may  obtain  their  explanation  in  morbid  conditions  of 
the  uterus. 

The  sexual  tone  prescribes  the  conditions  of  peristalsis 
generally,  including  capillary  activity,  and  prostatic  conditions 
determine  sexual  tone.  In  other  language,  the  prostate  gland 
is  the  key  to  male  sexual  force.  It  is  the  great  sexual  nerve 
center,  and  dominates  sexual  activity  and  power.  It  is  the 
central  office  of  the  sexual  telephonic  system,  and  its  authority 
is  supreme  in  the  sexual  domain.  Messages  issuing  from  this 
spot  control  sexual  conditions. 


7?- 


TAKEN  FROM  FLINT'S  PHYSIOLOGY. 

a,  vas  deferens:  6,  seminal  vesicle: 
c,  ejaculatory  duct:  d,  termination  of 
the  ejaculatory  duct:  e.  opening  of  the 
prostatic  utricle:  /,  g,  voru  montanum; 
h.  I,  prostate. 


TAKEN  FROM  FOSTER'S  PHYSIOLOGY. 

1,  the  urinary  bladder;  2,  the  longi- 
tudinal layer  of  muscular  fibres;  3,  the 
prostate  gland;  4,  membranous  portion 
of  the  urethra;  5,  the  ureters:  6,  blood 
vessels;  7,  left;  8,  right  vas  deferens: 
9,  left  seminal  vesicle  in  its  natural 
position;  10,  ductus  ejaculatorius  of  the 
left  side  traversing  the  prostate  gland; 
11,  right  seminal  vesicle  injected  and 
unravelled ;  12, 13,  blind  pouches  of  vesi- 
culae;  14,  right  ductus  ejaculatorius 
traversing  the  prostate. 


The  prostatic  inch  of  the  urethra  is,  therefore,  a  spot  of 
supreme  importance  in  the  sexual  domain.  Health  in  this  part 
means  normal  sexuality  and  its  attendant  blessings;  while 
pathology  here  involves  confusion  and  abnormal  states  of  all 
the  sexual  organs  and  its  systemic  consequences. 

As  rays  of  light  diverge  in  every  direction  from  a  lumi- 
nous body,  so  do  the  powers  of  sexual  commerce  start  from  the 


390 


ORIPIC1AL    SURGERY. 


prostatic  urethra  and  spread  in  various  directions  up  into  the 
prostate  itself,  by  means  of  the  prostatic  ducts ;  to  the  vesiculae 
seminales  and  testicles  by  way  of  the  vasa  deferentia ;  into  the 

bladder  by  way  of  the  os  vesi- 
cae,  and  to  the  point  of  the 
glans  penis  by  way  of  the  out- 
going urethra. 

The  prostate  gland  is  thus 
seen  to  be  an  organ  of  profound 
interest  to  the  orificial  surgeon. 
Messages  of  health,  and  sug- 
gestions of  disease  in  all  parts 
of  the  sexual  apparatus  reach 
their  destination  by  way  of  the 
prostatic  inch. 

The  orificial  principle,  that 
the  irritation  of  an  organ  starts 
at  its  mouth,  is  universally  true 
throughout  the  human  econ- 
omy. Applied  to  the  prostatic 
inch,  it  means  that  the  condi- 
tion of  the  testicles  depends  on 
the  condition  of  the  mouths  of 
the  ejaculatory  ducts  in  the 
prostatic  inch.  Applied  to  the 
bladder,  it  means  that  the  con- 
dition of  the  bladder  depends 
upon  the  os  vesicae.  Applied  to 
the  prostatic  itself,  it  means 
that  its  state  of  health  responds 
to  the  conditions  of  the  orifices 
of  the  prostatic  ducts  as  they 
open  into  the  prostatic  urethra. 
As  sexuality,  and  through  this  the  sympathetic  nerve 
force,  is  the  great  motive  power  of  the  world,  that  has  won 
the  great  battles,  solved  the  great  problems,  amassed  the  great 
fortunes,  composed  the  great  music,  and,  indeed,  is  responsible 


ORIFIC1AL   SURGERY.  391 

for  the  great  progress  of  civilization  in  the  history  of  the  race ; 
and  as  the  prostatic  inch  is  the  key  to  sexual  conditions,  the 
causes  which  operate  to  disorganize  it,  and  the  remedies  which 
are  efficacious  in  restoring  it  to  a  healthful  state,  deserve  the 
careful  and  continued  consideration  of  the  medical  fraternity. 

All  the  knowledge  which  we  possess  of  hypergesthesia  and 
hypertrophy,  anaesthesia  and  atrophy,  and  their  vari- 
ous causes,  will  find  a  fertile  field  for  application 
in  the  prostatic  inch.  We  must  familiarize  ourselves 
with  the  anatomy,  physiology,  and  the  pathology  of  this 
part,  as  well  as  with  effective  means  of  relief,  in  order  to  keep 
the  machinery  of  life  in  proper  balance  for  the  purposes  of 
our  existence.  Sexual  conclitons  fluctuate  our  hope,  our  cour- 
age, our  affections,  our  will-power,  and  our  intelligence  more 
than  those  of  any  other  part  of  our  human  structure. 

It  must  remain  for  a  later  article  in  this  series  to  con- 
sider the  causes  of  prostatic  pathology  and  its  cure ;  the  pres- 
ent object  being  simply  to  call  attention  to  the  importance  of 
maintaining  a  healthy  condition  of  the  prostatic  inch  of  the 
urethra,  in  order  to  furnish  an  adequate  supply  of  nerve  force 
for  the  continuance  of  a  vigorous  peristaltic  power  in  the  va- 
rious tubular  structures  of  the  body,  by  means  of  which  all 
the  activities  of  our  physical  natures  are  carried  on. 

The  teachings  of  the  orifieial  philosophy  are  so  plain, 
practical  and  effective  that  they  are  bound  to  revolutionize 
the  entire  treatment  of  chronic  diseases  in  the  male  as  well  as 
in  the  female  organizations.  As  the  importance  of  the  part 
becomes  better  appreciated,  as  a  knowledge  of  reflexes  and 
metastasis  of  irritation  and  congestion  become  more  thorough- 
ly discussed  and  better  understood,  the  prostatic  inch  will 
cease  to  be  so  commonly  neglected,  present  surgical  measures 
will  be  speedily  replaced  by  superior  ones,  and  the  longevity 
of  human  life  will  be  correspondingly  increased.  When  once 
the  great  truth  is  thoroughly  and  universally  recognized,  that 
normal  sexual  organs  are  an  essential  to  normal  activities 
throughout  the  entire  body,  doctors  will  begin  to  apply  what 
they  know  about  atrophy  and  hypertrophy,  about  anaesthesia 


392  ORIFIC1AL    SURGERY. 

and  hypergesthesia,  to  the  sexual  organs  as  well  as  the  rest  of 
the  body.  Sexual  nerve  waste  is  very  commonly  painless  and 
speaks  mainly  in  the  language  of  disturbed  function.  Doctors 
will  cease  to  regard  seminal  losses  as  normal,  because  they  will 
be  able  to  cure  them.  They  will  cease  to  ignore  the  mass  of 
universally  prevailing  conditions  of  perverted  sexual  tenden- 
cies, and  by  means  of  the  present  or  better  orificial  methods  re- 
deem the  race  from  its  present  pitiable  condition  of  sexual 
servitude. 

To  refresh  the  memory  of  our  readers  upon  the  anatomy 
of  the  male  sexual  organs,  although  our  present  purpose  is  not 
to  present  in  this  article  a  complete  anatomical  sketch  of  them, 
herewith  are  presented  a  few  cuts  "illustrating  the  mutual  re- 
lations of  the  various  organs  which  compose  the  sexual  appar- 
atus. 

CHAPTER  LI. 


CIRCUMCISION. 


E.   H.   PRATT,   M.   D. 


Sexuality  is  chiefly  responsible  for  all  that  is  -good,  great, 
grand  and  progressive  in  the  evolution  of  mankind.  Sensu- 
ality is  chiefly  responsible  for  all  that  is  mean,  morbid  and  con- 
temptible in  human  history.  Sexuality  has  been  the  chief  pro- 
pelling power  in  the  erection  of  churches  and  cathedrals,  school 
houses  and  libraries,  in  the  construction  of  steamboats,  rail- 
ways and  telegraph  and  telephone  wires;  its  purity  and  vigor 
have  had  to  do  with  the  best  books,  the  grandest  music,  the 
greatest  essays  and  poems  and  all  practical  inventions  that 
mart  the  progress  of  the  race.  The  enervating  influence  of 
sensuality  has  dimmed  the  noble  inspirations,  blunted  the  fine 
sensibilities,  paralyzed  the  worthy  efforts  and  polluted  the 
health  and  vigor  of  its  numberless  victims.  Sexualit.y  is  a 
grand  and  God-given  inspiration,  purifying  and  elevating  in 
its  tendencies.  Sensuality  is  a  God-forsaken,  mildewing  af- 


ORIFIC1AL   SURGERY.  393 

fliction  that  blights  everything  and  everybody  with  whom  it 
comes  in  contact.  From  a  doctor's  standpoint  sexuality  is 
an  expression  of  bodily  health,  while  sensuality  is  an  ex- 
pression of  bodily  disease.  There  are  some  in  our  profession 
who  are  charitable  enough  for  the  frailities  of  humanity  to 
construe  them  in  the  light  of  morbid  conditions.  It  is  not  nat- 
ural to  limp,  or  wheeze,  or  cough  or  cry;  it  is  no  more 
natural  to  lie,  or  steal,  or  commit  adultery.  All  deformities 
of  mind  or  matter  have  their  incipient  suggestion  in  bodily 
infirmities.  If  this  position  is  tenable  or  even  partially  so,  it 
becomes  an  important  matter  to  examine  each  body  carefully 
to  ascertain  its  deviations  from  normal  standards  of  perfection. 
If  the  male  sexual  organs  of  mankind  were  subjected  to  a 
critical  examination  with  the  idea  of  judging  of  their  approach 
to  an  ideal  standard  of  perfection,  the  number  which  would 
pass  muster  as  perfectly  normal  in  every  particular  would  be 
so  few  as  to  be  a  startling  disclosure  of  the  true  source  of  a 
very  large  percentage  of  the  weaknesses  and  sicknesses  of  hu- 
manity; for  sexual  abnormalities  predispose  to  sensuality  and 
its  various  and  disastrous  sequences.  They  are  perpetual 
sources  of  temptation,  nerve  waste  and  disaster  while  they  are 
permitted  to  remain  uncorrected.  They  are  usually  a  pain- 
less affliction  and  consequently  all  the  more  subtle  in  their 
mischief.  Our  ideals  are  the  composites  of  our  knowledge 
and  experience,  and  in  deciding  between  what  is  normal  and 
what  is  morbid  in  the  conformation  of  the  male  sexual  or- 
gans, the  decision  will  depend  upon  the  standard  of  excellence 
which  each  physician  or  surgeon  has  established  for  himself. 
In  discussing  this  subject  I  can  only  speak  of  my  personal 
standard  of  excellence  and  preferred  methods  for  the  correc- 
tion of  the  various  forms  of  deviation  from  it,  expecting  that 
many  of  the  readers  of  the  Journal  differ  from  me  more  or 
less  radically.  The  most  frequent  and  I  believe  most  important 
sexual  abnormality  in  the  male  sex  is  exhibited  in  the  confor- 
mation of  the  foreskin.  An  ideal  foreskin,  measured  by  the 
standard  which  I  have  long  since  adopted,  loosely  covers  the 
corona  glandis  and  upper  half  of  the  glans  penis,  and  retracts 


394  ORIFIG1AL    SURGERY. 

easily  and  without  compression  of  the  glans  or  constriction  of 
the  corpus  immediately  above  it.  Upon  extreme  retraction  of 
the  foreskin  there  is  no  adhesion  to  the  glans  or  its  corona  and 
no  tendency  of  the  fraenum  to  depress  the  point  of  the  penis. 
The  foreskin  which  completely  covers  the  glans  penis  while  in 
a  relaxed  state  of  the  organ  is  too  long.  One  which  compresses 
it  snugly  upon  retraction  is  too  tight.  One  that  depresses  the 
penis  upon  retraction  has  too  short  a  fraenum.  The  commonest 
deformity  is  where  the  foreskin  is  too  long,  or,  in  other  words, 
redundant.  The  nude  figures  of  ancient  statuary  and  the  nude 
paintings  by  the  recognized  masters  almost  invariably  illus- 
trate this  type  of  malformation  and  also  prove  it  to  be  so  com- 
mon as  to  be  considered  by  the  uninitiated  as  normal.  The 
practice  of  circumcision  received  a  perceptible  blow  at  the 
recent  World's  Exhibition  in  Chicago.  The  numerous  nude 
paintings  and  statuary  there  exhibited  were  not  discussed  in 
this  particular,  but  they  were  observed  and  the  sightseers, 
not  allowing  for  the  fact  that  a  good  artist  was  probably  a  poor 
doctor,  accepted  the  published  deformity  as  a  standard  of  ex- 
cellence. It  will  take  much  education  and  discussion  to  cor- 
rect the  wrong  impression  concerning  this  subject  which  has 
thus  quietly,  but  at  the  same  time  effectually,  been  made. 

After  an  unusually  extended  and  careful  study  of  this 
whole  subject,  with  an  ambition  to  be  extremely  conservative, 
I  regard  a  redundant  foreskin  as  inimical  to  the  health  and 
happiness  of  its  possessor  regardless  of  his  age  or  apparent 
condition.  To  illustrate  the  influence  which  an  enlongated 
and  adherent  foreskin  has  upon  the  nutrition  of  the  body,  I 
beg  to  submit  for  the  consideration  of  the  readers  of  the  Jour- 
nal one  of  the  many  cases  which  led  me  to  realize  that  our 
nutrition  and  the  funtional  activity  of  all  our  organs  are  un- 
der the  control  of  the  sympathetic  nerve,  and  that  the  fore- 
skin which  is  supplied  by  the  same  nerve  exercises  a  wonder- 
ful influence  over  all  the  bodily  suggestions  and  conditions. 
More  than  thirty  years  ago  I  was  summoned  to  inspect  the  con- 
dition of  a  child  who  was  evidently  suffering  from  marasmus. 
It  was  about  nine  months  old  and  at  that  time  weighed  one 


ORIFIG1AL    SUBGEEY. 


395 


pound  less  than  at  three  months  of  age.  It  was  emaciated  to 
an  extreme  degree,  had  no  appetite,  was  frequently  afflicted 
with  nausea  and  had  never  enjoyed  a  good  night's  sleep  or  a 
single  meal.  It  was  not  teething  and  appeared  to  be  well 
formed  except  that  its  entire  body  had  an  extremely  hungry 


FIG.  l. 

look.  Its  bowels  were  regular  and  its  urine  apparently  nor- 
mal. A  few  prescriptions  checked  the  nausea  but  did  not  in- 
crease the  appetite  or  relieve  the  restlessness,  wakefulness  and 
fretfulness,  and  a  change  of  climate  was  ordered  and  secured. 
After  three  months'  absence  from  home  I  was  again  called  to 
inspect  its  condition  and  was  much  alarmed  at  the  state  in 
which  I  found  it.  Its  condition  of  malnutrition  had  increased 
rather  than  diminished  and  it  was  becoming  dropsical  in  its 
little  feet  and  lower  limbs.  Counsel  was  called,  its  gums  were 
lanced,  drugs  were  administered,  its  appetite  was  tempted  by 
a  change  of  food,  but  all  to  no  avail.  The  dropsical  condition 
continued  until  the  lower  half  of  the  child  was  badly  swollen. 
At  my  request  the  infant  was  stripped  and  I  gave  it  a  careful 
examination  from  head  to  foot.  I  found  nothing  to  criticize 
except  a  redundant  and  adherent  foreskin.  Not  realizing  at 
the  time,  as  I  have  since  been  compelled  to,  the  numerous  and 
serious  pranks  which  this  condition  can  play  with  a  human 


396 


ORIFIC1AL    SURGERY. 


body,  I  did  not  consider  the  condition  of  the  foreskin  at  all  re- 
sponsible for  the  lowered  vitality  of  the  child ;  but  not  knowing 
what  else  to  do,  I  advised  the  mother  to  permit  me  to  slit  the 
foreskin  along  the  dorsum  and  loosen  its  attachment  to  the 
glans.  The  mother  gave  her  consent  and  the  task  was  easily 
and  quickly  accomplished.  Imagine  my  astonishment  as  well 
as  satisfaction  at  the  sequel.  That  night  it  slept  without  wak- 
ing, for  the  first  time  in  its  life.  The  next  morning  it  was 
hungry.  Within  twenty-four  hours  the  dropsical  condition 


began  to  pass  away,  and  by  the  end  of  a  week  had  entirely 
disappeared  and  the  child  was  dismissed  as  cured,  the  mother 
having  received  instructions  to  separate  the  lips  of  the  wound 
daily  to  prevent  a  return  of  the  condition.  Two  weeks  later 
the  mother  in  a  state  of  frenzy  presented  herself  at  my  office, 
begging  me  to  visit  her  child  once  more,  as  it  was  dying.  She 
was  so  beside  herself  that  she  could  not  describe  the  child's 
condition,  and  I  could  not  imagine  what  unhappy  change  had 
set  in.  I  shall  never  forget  the  picture  which  greeted  my  eyes 
as  I  entered  the  room  where  the  little  sufferer  lay  in  his  moth- 
er's lap.  The  dropsy  had  returned,  but,  instead  of  attacking 
the  lower  half  of  the  body,  had  taken  the  form  of  hydrocepha- 
lus.  Water  had  accumulated  in  the  subaraclmoid  space  to 


ORIFIG'IAL   SURGERY. 


397 


such  an  extent  that  the  frontal  bones  were  forced  prominently 
beyond  the  eyebrows,  causing  the  eyes  to  appear  as  deeply 
receding.  The  entire  circumference  of  the  head  was  greatly 
increased  and  it  was  so  heavy  that  the  child  could  no  longer 
support  it  by  its  slender  neck.  Remembering  my  recent  ex- 
perience, I  asked  the  mother  if  she  had  separated  the  lips  of 
the  wound  daily  as  I  requested.  She  said  she  had.  I  asked 
to  examine  the  condition  and  was  refused  permission.  Recog- 
nizing that  the  mother  was  so  beside  herself  as  to  be  irre- 
sponsible for  her  actions,  I  insisted  upon  making  an  examina- 
tion and  did  so.  I  found  that  the  mother  had  failed  in  her 
efforts  to  keep  the  lips  of  the  wound  apart  and  that  the  mar- 


gins of  the  foreskin  had  reunited.  Sending  the  mother  from 
the  room  and  summoning  the  nurse,  I  then  circumcised  the 
child  and  afterwards  gave  my  personal  attention  to  the  wound 
until  it  had  healed  satisfactorily  and  was  capable  of  free  and 
easy  retraction  beyond  the  corona  of  the  glans.  The  relief, 
I  am  delighted  to  say,  did  not  come  too  late.  Slowly  the  water 
about  the  brain  was  absorbed,  the  head  diminished  in  size  and 
in  two  weeks  the  condition  of  hydrocephalus  had  disappeared 
and  the  child  was  once  more  dismissed  as  cured.  For  many 
years  I  was  continuued  as  the  family  physician,  but  never  had 


398 


ORIFIGTAL    SURGERY. 


occasion  to  prescribe  for  the  baby  again  for  he  was  the  perfect 
picture  of  health.  I  met  the  father  fourteen  years  later  and 
he  informed  me  that  the  child  had  never  seen  a  sick  day  since 
and  was  then  grown  into  a  robust  and  healthy  young  lad. 

I  have  previously  described  this  case,  but  it  is  so  apropos 
in  the  present  connection,  and  it  presents  such  a  remarkable 
illustration  of  the  action  of  the  foreskin  over  the  nutrition  of 
the  body,  that  I  feel  confident  that  the  readers  will  pardon  my 
making  use  of  it  in  this  article. 

There  are  many  ways  of  performing  circumcision,  but  it 
would  be  a  waste  of  time  to  record  them  in  the  present  con- 
nection. The  operation  which  I  shall  now  describe  is  so  easy  of 


FIG.  4. 

accomplishment,  so  mathematically  exact  in  its  application  to 
all  cases  and  so  thoroughly  satisfactory  as  to  supplant  all  oth- 
ers in  my  estimation.  It  is  the  product  of  an  extended  experi- 
ence with  this  operation,  based  upon  a  suggestion  which  was 
made  to  me  by  Dr.  J.  M.  Walker,  of  Denver.  Dr.  Walker  in 
circumcising  children  found  that  by  the  aid  of  a  double  uter- 
ine tenaculum  he  could  seize  the  opposite  margins  of  the  fore- 
skin and  produce  sufficient  tension  to  enable  him  to  amputate 
the  foreskin  at  any  desirable  point.  As  my  practice  called 
upon  me  to  circumcise  adults  as  well  as  children,  I  found  the 


ORIFIG1AL   SURGERY. 


399 


double  tenaculum  insufficient  for  the  purpose  and  so  made 
use  of  two  separate  tenacula  and  a  pair  of  T  forceps  to  ac- 
complish the  same  purpose. 

The  fraenum  is  first  to  be  tested  by  practicing  extreme 
retraction  of  the  foreskin.  If  too  short  it  is  to  be  severed.  The 
meatus  is  then  to  be  examined  and  if  too  narrow  is  to  be  en- 
larged at  its  lower  extremity.  The  foreskin  is  then  to  be  re- 
placed in  its  normal  position.  Searching  its  lower  border  for 
the  point  at  which  the  mucous  membrane  which  lines  the 
foreskin  becomes  continuous  with  the  integument  which  cov- 
ers it,  a  Pratt  tenaculum  is  made  to  transfix  it  on  the  under 


FIG.  5. 


side.  The  instrument  is  now  passed  to  the  hands  of  an  assist- 
ant and,  while  sufficient  traction  is  being  exercised  to  straight- 
en the  tissues,  another  tenaculum  is  inserted  directly  opposite 
at  the  margin  of  the  foreskin.  While  the  assistant  is  render- 
ing the  foreskin  tense  by  means  of  these  tenacula  in  such  man- 
ner as  to  give  its  opening  the  appearance  of  a  long  narrow 
slit  extending  at  right  angles  to  the  direction  of  the  organ, 
the  intervening  margins  of  the  foreskin  are  secured  in  the  grip 
of  a  T  forceps  midway  between  the  tenacula.  (Fig.  1.)  The 
tissues  are  to  be  held  tense  by  traction  upon  the  tenacula  and 
T  forceps;  the  mucous  membrane  lining  the  foreskin,  by  its 


400  ORIFIGIAL    SURGERY. 

attachment  to  the  corona,  limits  the  possibilities  of  tension  so 
that  there  is  no  danger  of  stretching  the  tissues  too  far.  The 
operator  can  now  easily  locate  with  the  thumb  and  finger  of  one 
hand  the  position  of  the  point  of  the  glans  penis.  A  sharp, 
narrow-bladed  scalpel  is  now  made  to  pierce  the  foreskin  be- 
neath the  attachment  of  the  T  forceps  on  a  level  with  the 
point  of  the  glans  penis.  (Fig.  2.)  The  cutting  edge  of  the 
knife  is  to  be  turned  toward  the  under  side  of  the  organ  and 
the  lower  half  of  the  foreskin  severed  on  a  line  parallel  with 
its  free  margin.  (Fig.  3.)  A  pair  of  scissors  is  now  employed 
to  amputate  the  remaining  half.  (Fig.  4.)  In  doing  so  the 
scissors  are  opened  and,  starting  from  the  upper  edge  of  the 
wound  made  by  the  introduction  of  the  scalpel,  the  foreskin 
is  to  be  severed  from  below  upward  in  a  line  not  parallel  with 
the  margin  of  the  foreskin  as  was  practiced  with  the  lower 
half,  but  curving  upward  and  backward  at  an  angle  sufficient 
to  make  the  upper  angle  of  the  amputation  on  a  level  with 
the  edge  of  the  corona.  This  is  practically  removing  a  V- 
shaped  piece  from  the  dorsum  of  the  foreskin.  The  severed 
margins  of  the  skin  and  mucous  membrane  are  now  to  be  su- 
tured by  interrupted  catgut  sutures,  after  which  another  cat- 
gut suture  is  to  be  employed  to  close  the  amputated  foreskin 
over  the  point  of  the  glans.  (Fig.  5.)  The  object  of  this  last 
procedure  is  to  hold  the  foreskin  moderately  tense  over  the 
glans  while  the  raw  surfaces  are  agglutinating:  otherwise 
erections,  which  are  liable  to  supervene  from  the  presence  of 
stitches,  would  cause  the  foreskin  to  retract  back  of  the  glans, 
and  either  interfere  with  the  healing  of  the  wound  or  ensure 
its  healing  in  a  thickened  ring  of  tissue  which  would  remain 
permanently  retracted  about  the  margin  of  the  corona.  Many 
surgeons  prefer  to  amputate  the  entire  foreskin,  thus  leaving 
the  glans  and  corona  permanently  exposed.  This  I  believe  to 
be  unnecessary  and  much  prefer  securing  the  ideal  result  out- 
lined earlier  in  the  present  article,  namely,  a  foreskin  which  is 
worn,  when  the  organ  is  relaxed,  in  a  manner  which  covers  the 
corona  and  the  upper  half  of  the  glans,  leaving  merely  the 
apex  and  lower  half  exposed.  As  the  sutures  employed  are 
catgut  they  will  not  require  removal. 


ORIFICIAL    SURGERY.  401 

In  cases  where  adhesions  between  the  foreskin  and  glans 
are  encountered,  these  should  be  broken  up  before  circumcis- 
ion is  performed.  Subsequent  to  the  operation  in  such  cases, 
the  adhesions  between  the  glans  and  prepuce  will  reform;  but, 
after  the  severed  margins  of  the  mucous  membrane  and  skin 
are  well  united,  they  can  easily  be  broken  up  and  kept  from 
uniting  by  daily  anointing  with  cold  cream  or  carbolated 
vaseline. 

Circumcision  is  practiced  by  some  surgeons  under  the 
action  of  cocaine  hypodermically  employed,  but  as  cocaine  pre- 
disposes to  hemorrhage,  interferes  with  the  healing  and  its 
employment  hypodermically  is  accompanied  with  more  or  less 
danger,  it  seems  to  me  preferable  to  perform  the  operation 
under  the  action  of  an  anaesthetic,  a  mixture  of  ether  and 
chloroform  being  my  choice  for  grown  people  and  chloroform 
for  children. 

CHAPTER  LII. 


CIRCUMCISION. 


T.   E.   COSTAIN,   M.   D. 


This  subject  was  assigned  me  by  the  secretary,  and  al- 
though it  involves  the  consideration  of  the  entire  sexual  sys- 
tem from  an  orificial  standpoint,  I  shall  endeavor  to  adhere  to 
my  text  as  nearly  as  possible. 

Before  taking  up  the  consideration  of  operative  proced- 
ure, let  us  first  consider  the  anatomical  and  physiological  re- 
lation and  nerve  supply  of  the  foreskin  to  the  adjacent  struc- 
tures and  through  them  to  the  entire  economy. 

The  nerve  mechanism  of  the  foreskin  in  male  and  female 
is  so  closely  connected  and  intertwined  with  that  of  its  adja- 
cent tissue  as  to  bring  these  parts  in  close  communication. 
The  sympathetic  nerves  extensively  supply  the  erectile  tissue 
of  the  foreskin  and  glans  penis  in  the  male  and  the  glans  cli- 
toridis  with  its  surrounding  structure  in  the  female. 

LL-t*Lr    01- 


402  ORIFIGLAL    SURGERY. 

The  erectile  tissue  possesses  rhythmical  action,  besides 
being  supplied  with  nerves  from  the  lumbar  plexus  (gentio- 
crural)  and  the  sacral  plexus  (pudendal  and  internal  pubic). 
This  latter  chiefly  supplies  the  glans  penis  or  glans  clitoridis 
with  large  branches  terminating  with  tactile  or  genital  cor- 
puscles. The  mechanism  of  these  nerves  associates  the  geni- 
tals with  certain  muscles  and  overlying  skin.  These  parts  are 
closely  associated  by  the  sympathetic  nerve  with  all  the  pelvic 
and  abdominal  viscera.  The  cerebro-spinal  nerves  supply  the 
skin  and  muscles  associated  with  the  genitals  and  the  skin 
of  the  adjacent  organs  is  closely  associated  with  these  parts 
branches  coming  from  the  same  nerve  trunk.  What  affects  the 
periphery  of  one  affects  that  of  the  other.  Both  must  be  nor- 
mal or  reflexes  will  arise.  By  means  of  the  pudic  nerve  and 
small  sciatic  the  skin  and  muscles  of  the  vulva,  perineum  and 
anus  are  brought  into  harmonious  relation  with  the  gluteal 
muscles  (of  coition)  and  skin  over  them. 

The  numerous  reflexes  in  the  pelvic  region  will  bear  close 
observation  in  their  relation  to  each  other.  You  have  all  ob- 
served the  retention  of  urine  after  an  operation  on  the  rectum, 
and  it  has  frequently  been  demonstrated  in  this  clinic  that 
putting  a  forceps  on  the  foreskin  will  cause  defecation.  These 
reflexes  may  be  of  sympathetic  or  cerebrospinal  origin  to  the 
various  centers  or  may  originate  over  one  and  terminate  over 
the  other,  so  closely  associated  are  these  parts. 

In  view  of  all  this,  let  us  consider  the  foreskin  itself  for 
a  moment.  It  must  extend  no  farther  than  the  point  of  the 
glans  penis;  it  must  be  perfectly  free  from  adhesion  to  the 
glans  and  its  corona;  form  no  constriction  upon  the  glans  it- 
self; should  be  retracted  freely  and  easily  without  pinching, 
and  should  be  free  from  thickening  around  its  margin.  The 
deviations  from  this  standard  will  require  surgical  attention, 
not  only  because  of  the  local  abnormalities,  but  for  the  addi- 
tional reasons  which  can  readily  be  seen  by  tracing  the  ner- 
vous mechanism  of  these  parts  with  the  adjacent  organs. 

A  foreskin  protruding  beyond  the  glans,  no  matter  how 
free  from  constrictions,  is  too  long  and  should  always  be  am- 


[T/vfiG37£G    iG 


ORIFIC1AL   SURGERY.  403 

putated.  The  results  will  be  gratifying  and  always  beneficial. 
If  constricted  and  too  long,  the  amputation  should  be  carried 
well  over  the  dorsum  to  relieve  the  constriction  at  the  same 
time.  If  constricted  and  the  length  about  normal,  it  should 
be  slit  along  the  dorsum  sufficiently  to  relieve  the  abnormal 
contraction.  Should  a  rim  of  thickening  be  observed  around 
the  margin,  amputation  of  this  band  will  be  your  only  means 
of  causing  the  parts  to  present  a  normal  appearance  and  re- 
move the  constant  irritation  produced  on  the  sensitive  termi- 
nal endings  of  the  nerve  fibers. 

As  to  the  method  of  circumcision,  you  are  all  familiar 
with  one  or  more  ways  to  accomplish  the  object  sought.  My 
own  preference  is  the  method  used  by  Professor  Pratt  in  the 
clinics  you  have  just  witnessed. 

Let  us  now  consider  the  object  of  this  work,  in  addition 
to  the  local  comfort  and  the  relief  of  local  abnormalities,  as 
we  consider  them  to  be.  Experience  has  taught  me  that  much 
of  the  disease  and  weakness,  mental,  moral  and  physical,  of 
both  sexes,  may  be  prevented  or  relieved  by  proper  attention 
to  the  hygiene  and  the  correction  of  pathological  lesions  of 
the  sexual  system,  both  of  male  and  female.  Those  fortunate 
beings  who  have  been  free  from  sexual  irritations  will  un- 
doubtedly be  found  by  investigation  to  be  the  perfect  physical 
and  mental  types  of  manhood  or  womanhood  of  our  race.  On 
the  other  hand,  you  will  find  the  weak,  puny  and  sickly  speci- 
mens in  those  who  have  lacked  control  of  the  sexual  organs. 
The  question  goes  beyond  this,  however,  for  we  find  in  mere 
infants  the  results  of  past  generations,  and  every  obstetrician 
who  fails  to  examine  the  foreskin  of  the  boy  and  girl  at  birth 
submits  them  in  many  cases  to  disease  and  nervous  phenome- 
na as  a  handicap  to  their  physical  and  mental  development  at 
the  very  outset  of  their  existence,  and  even  life  itself  becomes 
extinct  from  a  lack  of  proper  attention  to  these  parts. 

It  is  not  the  experience  of  one,  but  of  many,  that  when 
children  fret,  seem  irritated  and  cry  constantly,  or  may  have 
rachitis,  hydrocephalus,  lack  of  mental  or  physical  develop- 
ment, or  many  other  conditions  of  childhood  too  numerous  to 


404  ORIFIG1AL   SURGERY. 

mention,  that  these  conditions  can  be  relieved  almost  at  once 
by  breaking  up  adhesions  of  foreskin  and  glans  or  by  circum- 
cision. These  experiences  are  so  common  to  the  observant 
physician  in  childhood  that  it  seems  a  pity  that  recognition  of 
these  facts  should  not  be  carried  to  the  relief  of  the  boy  or 
girl,  the  man  or  woman.  Fully  as  brilliant  results  can  be 
accomplished  by  the  doctor  who  will  bring  to  his  aid  the  re- 
lieving of  the  nerve  terminals  in  the  later  stages  of  human  de- 
velopment. 

Let  us  now  consider  the  sexual  apparatus  in  the  sexes  as 
a  whole  and  discover,  if  possible,  the  connection  between  the 
foreskin  and  the  adjacent  structures  in  the  male.  The  same 
nerve  supplies  the  foreskin,  urethra,  prostate,  ejaculatory 
ducts  and  bladder,  and  in  the  female  the  nerves  of  the  hood 
of  the  clitoris  are  only  branches  of  the  same  nerves  supplying 
the  urethra,  bladder,  vagina,  uterus,  tubes,  ovaries  and  rectum. 
If  then  we  have  pathological  lesions  of  the  foreskin,  what  an 
enormous  amount  of  damage  to  the  health  of  the  human  body 
can  be  going  on  all  the  time  through  reflexes  to  these  various 
parts,  and  even  through  them  to  the  great  center  of  life  itself, 
the  solar  plexus,  by  failing  to  recognize  the  necessity  of  the 
proper  hygienic  or  surgical  remedial  measures  to  the  foreskin. 

CHAPTER  LIII. 


LESIONS  ARISING   FROM   CONTRACTED   PREPUCE- 
TWENTY  CONSECUTIVE  ILLUSTRATIVE  CASES. 


J.   W.   MEANS,   M.   D. 


The  time-honored  custom  of  the  Jewish  people  of  circum- 
cising all  males  within  eight  days  after  birth,  had  not  only  a 
moral  and  religious  significance,  but  is  based  upon  a  principle 
more  scientific  than  this  age  of  self-worship  is  willing  to  con- 
cede. 

Centuries  have  passed  away  since  the  origin  of  this  cus- 
tom. In  fact,  it  might  be  termed  one  of  the  lost  arts,  and  not 


ORlFIClAL   SURGERY.  405 

until  the  last  generation  have  we  become  cognizant  of  the  im- 
portant facts  and  great  possibilities  underlying  the  seeming 
insignificant  operation  of  removing  a  contracted  prepuce. 

The  present  age  has  an  exaggerated  estimate  of  our 
achievements.  Wendell  Phillips  says :  ' '  We  seem  to  think  that 
knowledge,  whether  it  will  die  with  us  or  not,  certainly  began 
with  us." 

That  the  operation  of  circumcision,  as  performed  before 
the  Christian  era,  was  based  upon  a  knowledge  of  reflexew 
manifested  in  the  human  system,  and  not  upon  a  mere  cus- 
tom, is  evident  to  all  who  care  to  investigate  the  status  of  hu- 
man intelligence  at  that  early  period. 

While  the  idea  that  only  custom  prompted  the  operation 
is  in  harmony  with  our  self-conceit,  it  is  not  doing  justice  to 
a  once  intellectual  people,  whose  achievements  in  some  of  the 
sciences  and  arts,  at  least,  make  this  age  pale  with  insignifi- 
cance in  comparison. 

The  object  of  this  brief  recapitulation  is  to  call  your  atten- 
tion to  a  few  cases  of  reflex  troubles  resulting  from  contrac- 
tion of  the  prepuce. 

While  this  subject  may  be  considered  commonplace,  and 
somewhat  foreign  to  the  bureau  in  which  it  appears,  yet  it  is 
within  the  possibilities  of  some  of  our  more  astute  symptoma- 
tologists  to  effect  a  cure  of  this  condition  with  drugs  alone. 
While  I  admire  the  acumen  of  certain  prescribers,  and  ac- 
knowledge the  spirit-like  power  attributable  to  drugs  in  restor 
ing  the  equilibrium  of  the  body,  I  prefer  the  scapel  as  the 
remedy  "par  excellence"  in  the  treatment  of  reflex  disorders 
arising  from  contracted  prepuce. 

I  have  selected  twenty  consecutive  cases  occurring  in  my 
practice  during  the  last  two  years.  In  these  cases  there  was  a 
general  abnormal  condition  manifested  in  all,  but,  to  be  move 
specific,  the  age  and  particular  lesion  for  which  treatment  was 
given  is  hereto  appended. 

In  the  first  group  of  three,  whose  ages  were  respectively 
30,  22  and  18  years,  each  had  a  well  marked  case  of  Acne  Vul- 
garis.  Removed  contracted  prepuce  of  each  with  the  local 


406  ORIFIC1AL    SURGERY. 

anaesthesia  of  cocaine,  and  a  full-sized  metallic  sound  was  in- 
troduced into  the  urethra  beyond  the  prastrate  gland.  Com- 
plete cure  within  one  month  following. 

In  the  second  group,  in  which  we  find  five,  aged  respect- 
ively 13,  10,  8,  6  and  5  years,  we  have  in  all  Nocturnal  Enure- 
sis,  for  which  affliction  the  numerously  indicated  remedies 
were  applied  without  avail;  marked  elongation  and  hyper- 
trophy of  the  prepuce  existed  in  the  two  oldest  cases.  After 
circumcision,  complete  and  immediate  relief  in  each  case,  ex- 
cept the  oldest  of  the  group,  13  years,  chronic  cystitis  had  been 
induced,  and  only  after  persistent  treatment  did  he  fully  re- 
cover. 

In  addition  to  nocturnal  enuresis,  in  a  child  six  years  old 
I  found  inco-ordination  and  tremor — choreaic  movements  of 
the  lower  limbs,  simulating  spinal  sclerosis  so  closely  that  it 
had  been  diagnosed  by  a  leading  physician  of  our  city  to  be 
the  latter  disease,  and  pronounced  incurable.  Three  months  af- 
ter circumcision  the  child  was  entirely  well,  and  showed  no 
traces  of  the  once  formidable  disease. 

In  the  third  group  we  have  twelve  of  the  twenty  cases  re- 
ported, aged  from  five  to  one  and  a  half  years.  All  these  cases 
had  obstinate  diarrhea,  malnutrition,  slow  dentition :  two  with 
occasional  spasms.  While  the  operation  for  phymosis  was  per- 
formed on  all  these  cases,  the  indicated  remedy,  based  upon 
the  totality  of  symptoms  as  manifested  in  the  peculiar  charac- 
terestics  of  the  stool,  and  general  appearance,  was  persistently 
followed. 

One  striking  case  of  perpetial  contraction,  interfering 
with  the  whole  assimilative  process  and  intellectual  develop- 
ment, was  in  a  case  of  five  years  old  that  had  been  treated  by 
physicians  of  all  schools  of  medicine  for  malnutrition.  At  the 
age  of  two  years  the  child  was  bright  and  healthful,  nothing 
unusual  in  manner  or  size;  at  five  years  of  age  it  was  an  im- 
becile, could  not  walk  or  talk,  weighed  less  than  at  two  years 
of  age,  and  presented  a  pitiable  condition,  with  scarcely  a  ray 
of  hope  for  its  recovery.  On  examining  the  child  I  found 
hypertrophied  prepuce,  extending  fully  one  inch  beyond  the 
glans  penis.  Circumcision  was  immediately  performed,  and 


ORIFICIAL    SURGERY.  40? 

one  year  later  the  child  was  a  hearty,  robust  boy,  intelligent, 
mentally  active,  yet  unable  to  pronounce  a  word. 

Here  we  have  a  case  of  aphasia,  arising  from  neglect  on 
the  part  of  both  parents  and  physician  to  discover  in  time  the 
abnormal  condition  so  as  to  arrest  the  terrible  consequence 
resulting  from  the  contracted  prepuce. 

The  reflex  troubles  arising  from  this  lesion  alone  are  le- 
gion, and  the  crowded  almshouses  and  asylums  are  testimonials 
to  this  fact. 

CHAPTER  LIV. 


THE  MALE  MEATUS  AND  URETHRA. 


E.    H.    PRATT,    M.    D. 


Upon  examining  the  male  meatus  in  a  large  percentage  of 
cases  it  will  be  found  of  much  smaller  calibre  than  the  urethra 
beyond  it.  For  those  who  have  not  sufficient  confidence  in 
their  own  judgment  as  to  what  constitutes  a  normal  meatus  I 
would  suggest  the  employment  of  the  Otis  bulb  graded  sounds, 
of  which  the  following  cut  is  an  illustration,  as  a  means  of  ar- 
riving at  a  satisfactory  conclusion.  The  meatus  should  be  di- 
latable to  the  extent  of  the  urethra  so  that  in  passing  in  or 
withdrawing  a  bulbous  instrument  which  fits  the  urethra  snug- 
ly, no  considerable  resistance  should  be  met  with  at  the 
meatus.  When  obstruction  at  this  point  is  noticeable  the 
meatus  should  be  enlarged  to  a  sufficient  extent  to  permit  the 
free  and  unobstructed  passage  of  the  bulb  into  the  urethra, 
meaning,  of  course,  a  bulb  of  sufficient  size  to  fit  the  urethra 
snugly. 

It  is  a  simple  matter  to  enlarge  the  meatus.  For  this  pur- 
pose a  bistoury  or  a  pair  of  scissors  may  be  employed,  making 
the  cut  always  on  the  under  side.  In  many  cases  the  narrow- 
ing of  the  urethra  will  be  found  due  to  a  thin  membrane  which 
constricts  the  meatus  at  its  lower  fourchette,  and  in  most 
cases  the  severing  of  this  membrane  furnishes  sufficient  en- 


408  ORIFIC1AL   SURGERY. 

largement.  Occasionally,  however,  the  cut  must  be  made  fur- 
ther back,  severing  a  part  of  the  corpus  spongiosum  which 
sometimes  marks  the  seat  of  the  strictured  condition. 

It  is  possible  to  make  the  cut  too  generous,  as  the  entire 
severing  of  this  thickened  part  of  the  urethra  in  some  cases  de- 
stroys virility,  induces  inconvenience  in  urinating  and  might 
interfere  with  conception  as  it  detracts  from  ejectile  force. 
Personally  I  have  never  found  it  necessary  to  completely  sever 
this  thickened  part  of  the  corpus  sporigiosum  although  I  have 
frequently  found  it  necessary  to  sever  it  in  part,  preferring  to 
secure  the  desired  calibre  of  the  urethra  partly  by  dilatation 
if  necessary.  After  the  meatus  has  been  severed  it  invariably 
shows  a  marked  disposition  to  close  again,  so  that  the  ad- 
vantage can  only  be  maintained  by  daily  spreading  the  lips  of 
the  meatus  until  the  wounded  surfaces  have  cicatriced.  [Dr. 
Pratt  now  prevents  adhesion  and  closing  by  taking  a  stitch 
with  small  catgut  through  each  wounded  surface,  bringing  the 
lining  of  the  urethra  and  the  covering  of  the  glans  together. 
This  does  away  with  the  necessity  of  daily  spreading  the 
meatus. — Editor.  ] 


THE  FR^ENUM. 

To  the  median  line  of  the  under  side  of  the  glans  penis  is 
attached  a  narrow  strip  of  membrane  which  at  the  outer  ex- 
tremity reaches  as  far  as  the  poterior  fourchette  of  the  meat- 
us and  at  the  other  extremity  splits  into  two  crura  which  di- 
verge and  become  continuous  with  the  margin  of  the  foreskin 
on  each  side.  Another  way  to  describe  it  would  be  to  say  that, 
after  the  foreskin  had  been  constructed  around  the  glans 
penis,  the  lower  edge  of  it  was  gathered  up  and  fastened  to  the 
under  surface  of  the  glans  penis  as  far  as  the  meatus  so  as  to 
constitute  a  fraenum  or  bit,  one  margin  of  which  was  free  and 
the  other  margin  continuous  with  the  under  surface  of  the 
glans. 


ORIFIG1AL   SURGERY.  409 

The  possession  of  a  fraenum  is  not  an  abnormality,  but  on 
the  contrary  is  well  nigh  universal.  But  it  is  often  found  in 
what  we  have  now  learned  to  consider  an  abnormal  condition. 
The  test  for  the  proper  length  of  the  frgenum  is  retraction  of 
the  foreskin.  When  upon  extreme  retraction  of  the  foreskin 
the  frgenum  is  so  short  as  to  depress  the  point  of  the  glans 
penis,  it  is  now  considered  by  those  who  are  best  posted  on  the 
subject  to  be  abnormally  short  and  should  be  severed.  A  sat- 
isfactory manner  of  accomplishing  this  is  as  follows: 

While  the  fraenum  is  made  tense  by  retracting  the  fore- 
skin and  pushing  the  point  of  the  penis  backward,  one  blade 
of  a  pair  of  scissors  or  the  point  of  a  scalpel  is  pressed  against 
the  fraenum  upon  one  side,  the  instrument  being  held  at  right 
angles  to  the  penis.  Before  the  cut  is  made  the  handle  of  the 
cutting  instrument  should  be  carried  either  to  the  right  or  left 
sufficiently  to  avoid  the  danger  of  cutting  too  deeply  and 
wounding  the  urethra.  It  is  always  desirable  to  avoid  wound- 
ing the  artery  of  the  fraenum  if  possible,  although  this  is  some- 
times unavoidable  and  is  not  a  serious  accident  when  it  oc- 
curs. In  infants  the  fraenum  is  so  delicate  in  structure  as  to 
resemble  tissue  paper  and  can  be  sufficiently  broken  by  bend- 
ing the  glans  penis  as  far  as  possible  backward  with  the 
thumbs,  thus  tearing  the  delicate  membrane.  It  is  well,  how- 
ever, to  nick  the  margin  of  the  fraenum  before  breaking  its 
base  so  as  to  insure  the  tear  taking  place  at  a  desirable  point. 
The  part  of  the  fraenum  which  still  clings  to  the  glans  penis 
is  now  to  be  clipped  away  with  the  scissors.  Occasionally 
cases  will  be  encountered  in  which  the  retraction  of  the  fore- 
skin will  depress  the  glans  penis  and  yet  the  fraenum  be  en- 
tirely absent.  This  is  due  to  an  abnormal  shortening  of  the 
corpus  spongiosum  which  can  be  remedied  by  nicking  its  sur- 
face and  bending  the  glans  penis  backward  with  the  thumbs. 
Great  care  is  necessary  in  such  cases  to  avoid  snipping  or  lac- 
erating the  urethra.  The  surgeon  can  judge  of  the  thickness 
of  the  part  by  passing  the  sound  and  examining  the  tissues  over 
it.  The  condition  of  the  meatus  and  fraenum  has  more  to  do 
with  the  habits  and  consequent  happiness  and  health  of  men 
than  has  been  heretofore  appreciated,  and  the  correction  of 


410  ORIFICIAL    SURGERY. 

malformations  of  these  parts  will  do  much  toward  the  eradica- 
tion of  lustful  tendencies,  while  they  will  not  interfere  with 
the  employment  of  legitimate  sexual  sentiments  and  powers. 
While  the  wound  occasioned  by  the  severing  of  the  fraenum 
is  healing,  the  foreskin  should  be  retracted  daily  so  as  to  pre- 
vent a  recurrence  of  the  trouble. 

THE  URETHRA. 

There  is  little  of  importance  to  the  orificialist  in  the  male 
urethra  after  the  proper  condition  of  the  meatus  has  been  se- 
cured until  the  prastatic  portion  is  reached.  Strictures  of  the 
urethra  between  these  two  points  are  common  and  are  either 
spasmodic  or  organic.  The  spasmodic  strictures  are  almost  in- 
variably reflected  from  difficulties  at  either  the  extremity  of 
the  penis  or  the  rectum,  and  their  cure  is  assured  by  the  re- 
moval of  their  cause.  Organic  strictures  are  a  product  of 
venereal  disease  and  do  not  call  for  consideration  in  the  pres- 
ent article.  This  subject  has  been  exhaustively  treated  in  so 
many  standard  publications  that  I  will  respectively  refer  the 
reader  to  them  for  its  consideration.  The  patients  to  whom 
orificial  treatment  is  applicable  are  not  merely  those  who  have 
been  punished  by  their  morbid  propensities  by  syphilis  and 
gonorrhea  and  their  sequals,  nor  those  who  suffer  from  night 
losses,  or  who  have  practiced  or  are  practicing  masturbation, 
or  who  are  in  the  habit  of  indulging  in  excessive  intercourse, 
legitimate  (so-called),  or  otherwise,  for  orificial  effects  can 
be  attained  in  the  various  forms  of  chronic  disease  in  men  of 
the  most  correct  habits  and  apparently  normal  sexual  condi- 
tion. All  chronic  conditions,  both  local  and  general,  are  sub- 
jects for  orificial  work;  however,  we  will  give  a  brief  con- 
sideration to  the  more  important  local  as  well  as  general  con- 
ditions from  the  orificial  standpoint. 

[This  language  may  be  misleading^  if  not  carefully  noted,  by  imply- 
ing that  orificial  treatment  offers  no  relief  to  those  with  incorrect  habits 
and  abnormal  seual  conditions.  We  are  sure  the  author  did  not  in- 
tend to  convey  this  impression.  Orificial  surgery  offers  the  most  potent 
and  permanent  relief  to  the  libidinous  individual  who  masturbates  or  in- 
dulges in  excessive  venery.  It  changes  'his  focus  of  attention;  it  breaks 
the  shackles  of  passion  and  makes  the  slave  a  free  man;  the  fire  which 
is  consuming  the  building  is  confined  and  controlled  to  its  intended  uses; 


ORIFIG1AL   SURGERY.  411 

it  leads  from  the  hard,  rugged  road  of  the  transgressor  to  green  pastures 
beside  the  still  waters.  Relieving  impingement  of  sympathetic  nerve 
terminals  in  the  lower  openings  of  the  body  sends  a  message  over  the 
life-wires  to  the  sanctum  sanctorium  of  the  soul  that  may  be  transmitted 
to  the  shores  of  eternity. — Editor.] 

First,  then,  a  brief  word  about  strictures.  They  usually 
occur  in  the  body  of  the  urethra,  between  the  glans  and  the 
prostate.  Attention  to  the  urethra  itself,  either  by  the  employ- 
ment of  dilatation  or  the  urethrotome,  is  not  sufficient  for  their 
cure.  The  extremity  of  the  penis  must  be  put  in  proper  con- 
diticm  and  rectal  abnormalities,  which  will  always  be  found 
accompanying  these  troubles,  must  be  corrected  in  order  to 
secure  rapid,  satisfactory  and  permanent  results.  Many  spe- 
cialists, who  have  given  their  undivided  attention  to  the  ureth- 
ra, have  ignored  the  influence  of  rectal  conditions  upon  this 
part  and  are  consequently  abusing  it  beyond  its  deserts.  I 
believe  that  urethrotomy  is  almost  never  necessary  if  due 
respect  is  paid  to  orificial  principles  when  treating  urethral 
strictures.  It  was  while  handling  an  extensive  surgical  clinic, 
replete  with  gonorrhea  and  all  its  stages  and  sequences,  that 
the  orificial  philosophy  was  born.  The  difficulties  encountered 
in  curing  gleet  and  urethral  strictures,  and  the  fact  that 
these  difficulties  vanished  as  soon  as  orificial  principles  were 
applied  to  them,  had  much  to  do  with  the  earlier  development 
of  the  thought,  which,  of  course,  was  soon  found  to  be  ef- 
ficacious, not  only  in  curing  pelvic  troubles,  but  in  general  dis- 
orders of  the  system  as  well. 

After  a  stricture  has  been  thoroughly  and  persistently  di- 
lated until  all  raw  surfaces  have  healed,  the  reason  of  its  re- 
turn, which  almost  invariably  occurs  later  on,  is  not  to  be 
found  at  the  seat  of  the  stricture,  but  in  some  form  of  orificial 
irritation.  As  soon  as  the  rectum  and  extremity  of  the  penis 
are  placed  in  proper  condition  and  the  urethra  once  thor- 
oughly relieved,  the  stricture  will  permanently  disappear  with- 
out the  employment  of  the  urethrotome  or  even  electricity. 


412  ORIFIG1AL   SURGERY. 


CHAPTER  LV. 


THE  USE  OF  MALE  SOUNDS. 


E.   H.   PRATT,   M.   D. 


In  skillful  hands  urethral  sounds  are  invaluable  in  the 
treatment  of  all  forms  of  chronic  disease  to  which  men  are 
liable.  If  employed  awkwardly  or  unadvisedly  they  are  dan- 
gerous instruments.  Their  usefulness  is  confined  almost  en- 
tirely to  chronic  conditions  either  local  or  general.  If  em- 
ployed in  acute  cases  they  are  liable  to  induce  serious  aggra- 
vations. For  many  generations  urethral  sounds  have  been  em- 
ployed for  the  cure  of  gleet  and  stricture.  But  this  has  been 
the  limitation  of  their  use  until  the  development  of  the  ori- 
ficial  philosophy.  It  is  now  found  that  in  addition  to  what 
they  can  accomplish  in  local  troubles  resulting  from  gonor- 
rhoea and  its  sequences  they  are  indispensable  in  the  cure  of 
seminal  losses  and  impotency,  and  have  a  wide  range  of  use- 
fulness in  the  treatment  not  only  of  reflex  troubles  but  in  all 
other  chronic  affections  of  men  which  require  a  stimulus  of 
the  sympathetic  nerve  to  awaken  reactive  power. 

Skillful  handling  of  the  instruments  can  only  be  acquired 
by  a  knowledge  of  the  proper  manner  of  their  introduction 
and  by  frequent  practice.  The  adaptation  of  their  use  in  the 
various  forms  of  chronic  disease  in  which  they  are  serviceable 
is  an  art,  in  the  practice  of  which  some  general  directions  may 
be  helpful  but  nothing  but  an  extensive  experience  can  ever 
develop  correct  judgment. 

In  selecting  a  set  of  sounds,  those  are  better  which  taper 
slightly  at  the  tip,  and  they  should  be  carefully  graded  so 
that  the  small  end  of  each  sound  is  a  trifle  smaller  than  the 
largest  diameter  of  the  preceding  sound.  If  this  suggestion  be 
followed  it  is  not  necessary  for  an  operator  to  possess  each 
number,  the  sizes  increasing  by  one  and  a  half  numbers  being 
adequate  for  all  purposes.  No  steel  sounds  under  No.  10  are 
desirable,  as  in  cases  where  smaller  numbers  are  required 


ORIFIO1AL    SURGERY.  413 

urethral  bougies  are  safer.  Over-distension  of  the  urethra 
is  harmful.  It  is  both  unnecessary  and  undesirable,  and  con- 
sequently no  number  higher  than  a  No.  18,  English  scale,  will 
be  needed.  Over-dilatation  of  the  urethra  is  liable  to  induce 
enuresis  and  impotency,  and  the  full  benefit  of  the  instrument 
can  be  obtained  without  running  the  risk  of  over-distension. 

The  following  cut  illustrates  a  form  of  instrument  devised 
by  the  author.  These  double  sounds  are  fully  as  serviceable 
as  the  single  ones,  are  a  saving  in  both  number — and  conse- 
quently expense — and  weight.  They  are  best  made  of  steel, 
for  although  they  can  be  made  of  rubber  or  aluminum  and 
thus  made  lighter,  this  is  by  no  means  a  desirable  object. 


The  questions  of  importance  are: 

First.    How  properly  to  introduce  a  sound? 

Second.     How  long  to  hold  it  in  position? 

Third.    How  often  to  employ  it  or  them? 

Fourth.    Should  they  be  used  hot  or  cold? 

Fifth.    How  long  is  their  use  to  be  continued? 

Although  each  case  must  be  individualized,  nevertheless 
some  general  rules  covering  these  points  will  be  found  service- 
able. 

The  sound  is  to  be  lubricated  with  a  fine  quality  of  toilet 
soap.  Soap  is  the  best  lubricant  because  it  not  only  renders 
the  instrument  sufficiently  slippery,  but  favors  the  removal  of 
mucus  so  frequently  encountered  in  the  urethra  as  the  sound 
is  withdrawn.  It  is  harmful  to  use  vaseline  because  it  is  in- 
soluble in  urine  and  some  of  it  is  liable  to  remain  in  the  blad- 
der and  along  the  urethra  and  become  a  nest  for  the  develop- 
ment of  germs.  Post  mortem  examinations  have  frequently 
revealed  large  accumulations  of  vaseline  in  the  bladder,  which 
had  become  rancid  and  acted  as  a  source  of  vesical  irritation. 


414  OBIF1C1AL    SURGERY. 

There  is  no  objection  to  the  use  of  olive  oil,  except  that  its  use 
does  not  favor  the  extraction  of  the  mucous.  Soap,  being  en- 
tirely unobjectionable  in  every  particular  and  being  the  most 
cleanly  of  lubricants,  is  preferable. 

First.  The  proper  manner  of  introduction.  Standing 
upon  the  right  side  of  the  patient  as  he  lies  in  the  recumbent 
position,  the  operator  holds  the  lubricated  sound  in  his  left 
hand  in  such  a  manner  that  the  back  of  his  hand  rests  upon 
the  patient's  abdomen  and  the  instrument  extends  across  the 
palm.  The  penis  is  then  to  be  carefully  drawn  over  the  sound, 
which  is  now  gradually  lowered  until  the  instrument  is  hori- 
zontal with  the  hand  of  the  operator.  As  the  sound  is  now 
carefully  raised  it  is  also  carried  downward  as  nearly  as  pos- 
sible by  its  own  weight,  as  no  force  is  ever  to  be  employed  in 
the  manipulation  of  the  instrument.  Where  the  penis  is  ex- 
ceedingly flaccid,  as  it  frequently  is  in  the  aged,  it  should  be 
kept  in  a  condition  of  tension  by  the  right  hand  which  seizes 
the  organ  on  either  side  just  back  of  the  glans  penis.  The  in- 
strument is  made  then  to  continue  its  course  until  it  is  carried 
slightly  beyond  the  point  where  it  is  at  right  angles  to  the 
body,  and  will  consent  to  remain  in  this  position  after  all  ef- 
fort employed  in  its  introduction  is  withdrawn.  When  in  this 
position  the  tip  of  the  sound  will  have  passed  the  os  vesica?  and 
have  entered  the  bladder.  Care  must  be  exercised  to  avoid 
the  impinging  upon  the  inner  surface  of  the  bladder  with  the 
point  of  the  instrument,  as  perforations  are  possible  and  in- 
flammatory action  of  the  vesicus  could  easily  be  induced  by 
sound  bruise.  The  urethra  is  frequently  bruised  at  the  en- 
trance of  its  membranous  portion  by  failure  to  follow  the  canal 
accurately,  and  the  sound  may  not  reach  the  prostatic  inch, 
which  should  be  its  destination,  if  its  introduction  is  not  made 
complete.  As  the  sound  enters  the  bladder,  if  the  patient  is 
not  under  an  anesthetic  and  the  parts  are  normally  sensitive,  a 
sensation  of  passing  water  will  be  experienced  by  the  pa- 
tient and  be  an  indication  to  the  operator  that  the  neck  of 
the  bladder  has  been  effectually  entered  and  a  satisfactory  in- 
troduction has  been  accomplished. 


OKIFIC'IAL    SURGERY.  415 

Second.  How  long  shall  it  be  permitted  to  remain  in  situ? 
The  length  of  time  which  the  instrument  should  be  permitted 
to  remain  will  vary  with  the  different  eases,  from  the  mere  in- 
troduction and  immediate  removal  up  to  an  hour  or  perhaps 
even  two  hours,  according  to  the  torpidity  of  the  case  and  the 
degree  of  reaction  desired.  If  the  urethra  is  hyperesthetic 
its  immediate  removal  after  it  has  been  successfully  passed  is 
demanded.  If  the  case  be  one  of  impotence  or  seminal  losses, 
or  one  in  which  reactive  power  is  at  low  ebb  and  considerable 
sympathetic  stimulus  is  demanded,  it  should  be  held  in  posi- 
tion for  at  least  ten  or  fifteen  minutes  at  the  first  sitting.  If 
upon  its  removal  strings  of  mucus  are  found  clinging  to  its 
surface,  it  should  be  cleaned,  again  lubricated,  and  again 
passed  and  withdrawn  until  mucus  fails  to  appear  upon  its 
surface.  This  may  require  two  or  three  introductions  or  it 
may  require  a  dozen.  The  urethra  is  first  cleared  of  mucus  by 
the  aid  of  medium  sizes,  both  the  larger  and  smaller  ones  of- 
ten proving  ineffectual  in  bringing  it  away.  As  soon  as  mucus 
begins  to  appear  upon  the  sound,  the  same  sound  should  be 
used  until  the  mucus  has  disappeared  before  passing  on  to 
the  employment  of  a  larger  size.  In  attempting  to  pass  a 
sound  in  case  of  stricture,  where  it  is  impossible  to  effect  an 
introduction,  the  urethra  should  be  thoroughly  dilated  as  far 
as  the  strictured  point,  after  which  an  entrance  of  the  smaller 
sizes  can  be  much  more  readily  effected.  As  reaction,  either 
general  or  local,  is  the  object  of  the  use  of  the  instrument,  the 
length  of  time  for  leaving  the  sound  in  required  for  this  pur- 
pose is  to  be  sought  for,  always  being  careful  to  underdo. 

A  singular  experience,  furnished  by  a  case  of  paralysis 
some  years  ago,  gave  the  writer  a  valuable  point  as  to  the 
length  of  time  a  sound  might  be  left  in  the  urethra  in  desper- 
ate cases.  The  patient,  who  had  been  paralyzed  for  ten  years, 
applied  for  relief.  He  had  but  partial  use  of  his  lower  limbs 
and  no  control  of  either  urine  or  feces.  Orificial  worK  was 
performed  upon  him  twice,  at  intervals  of  one  year,  without 
effect.  He  wrote  for  further  instructions,  and  was  advised  to 
pass  a  sound  upon  himself  at  bedtime,  and  allow  the  instru- 
ment to  remain  in  position  for  half  an  hour.  He  attempted  to 


416  ORIFIG1AL    SURGERY. 

follow  the  instructions,  but  before  the  half  hour  expired 
dropped  off  to  sleep,  leaving  the  sound  in  position,  having 
propped  it  in  such  a  manner  that  it  was  retained  in  place  with- 
out the  use  of  his  hands.  Being  tired  he  slept  soundly  and 
awoke  in  the  morning,  eight  hours  later,  much  shocked  and 
chagrined  to  find  that  he  had  not  stirred  in  the  night,  and 
that  the  sound  was  as  he  had  left  it  when  dropping  to  sleep. 
He  removed  it,  but  although  being  a  physician  he  did  not  re- 
alize that  he  had  induced  a  severe  shock  to  the  urinary  tract 
and  his  system  in  general,  and  that  it  would  be  necessary  for 
him  to  exercise  extreme  caution  to  escape  severe  consequences. 
He  dressed  himself  and  took  a  long  ride  into  the  country.  By 
the  time  he  arrived  at  his  destination,  however,  he  was  taken 
with  a  severe  chill  and  was  too  ill  to  return  home.  Suppression 
of  the  urine  supervened,  extreme  congestion  of  the  kidneys 
followed,  and  for  forty-eight  hours  his  life  was  despaired  of. 
The  first  discharge  from  the  urethra  was  a  little  blood,  then 
a  few  drops  of  urine ;  finally  the  flow  was  re-established  and 
in  a  short  time  he  made  rapid  convalescense.  Much  to  his 
gratification  he  found  that  he  had  not  gone  through  his  ex- 
perience without  benefit.  He  had  been  wearing  a  urinal  for 
many  years,  but  found  to  his  delight  that  now  the  paralysis 
of  the  bladder  was  completely  cured  and  he  was  able  to  evacu- 
ate the  bladder  voluntarily  and  normally  in  every  way.  The 
cure  of  the  paralysis  remained  permanent,  and  not  till  the 
cure  was  effected  did  the  doctor  inform  me  of  his  carelessness. 
He  has  since  had  occasion  to  laugh  at  the  experience  as  the 
final  result  was  satisfactory. 

In  reflecting  upon  this  case  the  writer  speedily  reali/cd 
that  he  had  not  been  using  the  sounds  to  their  possibilities  of 
usefulness,  as  it  had  been  his  custom  previously  to  withdraw 
the  sound  after  letting  it  remain  in  position  a  short  time. 

Along  this  same  line  are  satisfactory  results  obtained  from 
the  use  of  uterine  stems  in  cases  where  the  mere  dilatation  of 
the  organ  produces  no  satisfactory  results.  In  bad  cases  of 
constipation  and  catarrh  of  the  sigmoid  much  benefit  can  be 
derived  from  packing  the  sigmoid  and  permitting  the  pack- 


ORIFIC1AL   SURGERY.  417 

ing  to  remain  for  twenty-four  or  forty-eight  hours,  or  even 
longer,  until  a  sufficient  degree  of  reaction  has  supervened. 

This  is  the  only  case  in  which  the  writer  has  known  a 
sound  to  be  left  in  position  for  eight  hours  in  succession;  and 
although  the  reaction  was  satisfactory,  it  was  a  dangerous 
proceeding.  It  is  perfectly  proper  for  a  surgeon  to  decide  the 
length  of  time  a  sound  is  to  be  left  in  position  by  the  require- 
ments of  the  case,  which  can  only  be  ascertained  by  repeated 
trials  at  longer  or  shorter  intervals  until  symptoms  of  satis- 
factory reaction  begin  to  manifest  themselves. 

Third.  How  often  shall  the  sound  be  employed?  Never 
oftener  than  twice  a  week  and  more  frequently  but  once  in 
one  or  two  weeks,  and  in  many  cases  once  in  from  one  to  three 
months  will  meet  the  requirements  of  the  case.  When  reaction 
is  once  aroused  the  sounds  are  to  be  employed  at  only  long 
intervals  and  for  a  short  duration  of  time,  to  avoid  the  dis- 
asters of  their  over-use.  In  cases  of  seminal  losses  and  im- 
potency  the  point  of  reaction  is  not  so  quickly  reached  and 
consequently  the  use  of  sounds  will  be  demanded  at  short  in- 
tervals and  it  will  be  necessary  to  protract  their  stay  in  the 
bladder  beyond  what  will  be  required  where  the  sexual  or- 
gans are  in  a  fairly  normal  condition  and  they  are  to  be  em- 
ployed for  a  stimulating  effect  upon  the  various  organs  and 
tissues  of  the  body  remote  from  the  pelvis:  It  is  a  fine  point 
to  determine  just  when  reaction  is  secured  and  the  use  of  the 
instrument  is  to  be  abandoned.  Increased  irritability  of  the 
urethra,  improvement  in  the  color  and  tonicity  of  the  organs 
themselves,  and  the  effect  produced  upon  the  general  health  of 
the  patient,  can  alone  determine  this  point.  When  the  use  of 
the  instrument  produces  an  aching  sensation  of  the  perineum 
or  a  hyperesthesia  of  the  testicles  or  backache  or  chilly  sen- 
sations, it  must  be  taken  for  granted  that  its  use  is  to  be 
abandoned  or  at  least  be  materially  lessened  in  frequency. 

Fourth.  Should  they  be  used  hot  or  cold?  If  for  merely 
the  local  purpose  of  relieving  strictures  or  curing  gleet,  they 
should  be  used  hot.  But  where  they  are  used  to  re-establish 
sexual  tonicity,  or  as  a  general  sympathetic  tonic,  they  had 


418  ORIFIC1AL    SURGERY. 

better  be  used  both  hot  and  cold.  The  heated  sound  is  first  to 
be  passed  and  permitted  to  remain  a  long  or  short  period  ac- 
cording to  circumstances,  and  after  its  removal  the  same  is  to 
be  passed  cold,  but  should  remain  in  position  no  longer  than 
thirty  seconds  or  one  minute  at  most.  Immediately  after  the 
removal  of  the  cold  sound — and  indeed  it  is  a  good  rule  to  fol- 
low universally  after  the  passage  of  sounds — the  point  of  the 
penis  should  be  held  in  warm  water  for  five  minutes  three  or 
four  times  a  day,  until  all  traces  of  a  smarting  or  burning  sen- 
sation in  passing  water  have  disappeared. 

Fifth.  How  long  is  their  use  to  be  continued?  There  is 
such  a  thing  as  a  "sound  habit."  It  is  very  easy  to  continue 
the  use  of  the  sound  to  the  harm  of  the  patient,  and  the  prac- 
tice had  much  better  be  under-done  than  over-done.  In  em- 
ploying them  for  the  restoration  of  sexual  tonicity  their  over- 
use would  tend  to  destroy  what  little  sexual  power  still  re- 
mained. In  cases  of  atony  of  the  bladder  and  weakness  of  the 
accelerator  urinae,  evidenced  by  difficulty  in  voiding  urine,  the 
small  size  of  the  stream  and  dribbling  of  urine  at  the  close  of 
the  effort,  too  prolonged  and  frequent  use  of  the  sounds  is 
liable  to  precipitate  the  case  into  one  of  complete  paralysis 
instead  of  restoring  the  weakened  muscles  to  their  proper 
tone.  Metaphorically  speaking,  they  are  edged  tools,  and  while 
handled  with  discretion  they  are  of  incalculable  benefit  in  the 
treatment  of  all  forms  of  chronic  diseases,  both  local  and  gen- 
eral, of  the  male  sex ;  if  injudiciously  or  awkwardly  employed 
they  are  equally  productive  of  mischief. 

CHAPTER  LVI. 


DISEASES  OF  THE  PROSTATE. 


E.   H.   PRATT,   M.   D. 


Prostatic  afflictions  are  liable  to  be  overlooked,  especially 
in  their  earlier  stages,  by  both  the  laity  and  the  profession. 
They  are  overlooked  by  the  laity  because  they  are  seldom  pain- 
ful, and  the  disorders  of  bodily  functions  which  may  fairly  be 


OBIPICl'AL   SURGERY.  419 

attributed  to  them  are  usually  referred  to  other  causes.  They 
are  liable  to  be  overlooked  by  the  medical  profession  for  three 
reasons:  First,  doctors  are  seldom  good  anatomists  or  physi- 
ologists, do  not  appreciate  the  unity  of  the  human  body  nor 
take  into  consideration  the  complicated  working  of  its  varied 
machinery;  second,  because  physical  examination  when  form- 
ing a  diagnosis  is  imperfect,  due  partly  to  the  fact  that  in  the 
answers  given  by  the  patient  to  the  doctor's  questions  no  im- 
pression is  conveyed  of  the  existence  of  prostatic  trouble 
simply  because  many  of  its  forms  are  painless;  and,  third, 
many  forms  of  prostatic  trouble  are  liable  to  escape  detection 
even  upon  what  is  commonly  considered  a  local  examination. 
The  laity  are  excusable  for  their  medical  mistakes  and  ignor- 
ance, but  the  profession  must  be  able  to  go  beyond  the  physi- 
cal expression  of  disease,  wherever  located,  and  unearth  its 
cause.  When  this  practice  becomes  a  habit  and  a  more  thor- 
ough education  furnishes  people  with  medical  men  who  are 
better  equipped  for  their  calling,  conditions  of  the  prostate 
will  assume  an  importance  in  medical  considerations  which 
they  have  long  deserved  and  never  yet  enjoyed. 

In  estimating  the  degree  of  attention  which  prostatic 
troubles  may  legitimately  claim  in  deliberations  which  have  for 
their  object  the  prevention  and  cure  of  human  suffering,  we 
must  bear  in  mind  that  sympathetic  nerve  power  and  reactive 
power  are  synonymous  terms.  Sympathetic  force  is  the  steam 
which  propels  the  entire  enginery  of  the  body.  When  it  is 
abundant  peristalses  are  vigorous,  capillary  circulation  is  nor- 
mal, and  health  prevails  throughout  the  various  tissues.  When 
it  is  deficient  peristalses  become  sluggish,  effete  matter  is  un- 
duly retained,  fresh  material  is  insufficiently  supplied,  capil- 
lary circulation  is  irregular  and  inadequate  to  the  renewal  and 
purification  of  the  tissues,  blood  stasis  results  in  whatever 
part  of  the  body  is  used  most  or  is  weakest  by  nature,  and 
pathology  finds  its  incipiency. 

This  sympathetic  power  upon  which  all  bodily  activity  de- 
pends is  the  nerve  force  which  sustains  the  prostate  and  its  be- 
longings, and  prostatic  troubles,  by  draining  this  nerve  force 
prodigally,  reduce  the  general  sympathetic  nerve  power  and 


420  ORIFIGTAL    SURGERY. 

consequently  the  tonicity  of  the  entire  body,  permitting  it  to 
be  the  unfortunate  prey  of  whatever  opposing  forces  it  encoun- 
ters. On  account  of  the  nerve  exhaustion  which  prostatic  dif- 
ficulties accomplish,  they  are  prone  to  be  one  of  the  primary 
causes  of  all  forms  of  chronic  disorder.  Skin  troubles,  mu- 
cous membrane  troubles,  head,  thoracic  and  abdominal  diffi- 
culties— in  fact,  the  entire  list  of  chronic  diseases  may  find  at 
least  a  part  of  their  explanation  in  nerve  waste  incurred  by 
prostatic  illness,  which  has  been  going  on  continuously  until 
it  has  exhausted  the  reactive  power  of  the  body,  but  so  silently 
as  to  escape  the  attention  of  both  patient  and  doctor.  It 
must  be  remembered  also  that  the  irritation  of  an  organ  starts 
at  its  mouth,  and  that  when  the  prostate  is  clogged  and  its 
functions  perverted  it  involves  the  disorder  of  all  organs  whose 
mouths  empty  into  the  prostatic  inch ;  from  above  is  the  blad- 
der with  its  renal  appendages,  from  below  comes  the  urethra, 
and  in  its  centre  are  found  the  ejaculatory  ducts,  which  are 
in  the  outer  openings  of  the  vesiculae  seminales  and  vasa  defer- 
entia,  and  also  the  prostatic  ducts  themselves.  The  prostatic 
inch  is  thus  seen  to  be  the  central  telephone  office  for  the 
male  pelvis,  and  its  influence  is  as  wide  as  sexuality  and  the 
urinary  functions,  for  which  the  part  stands. 

The  disease  forms  which  the  prostate  takes  on  when  its 
circulation  has  been  sufficiently  impeded  and  protracted  are 
similar  to  those  suffered  by  other  parts  of  the  body.  They 
can  be  malignant  or  benign;  then  can  be  atrophied  or  hyper- 
trophied.  Malignant  disease  of  the  prostate  is  fortunately  a 
very  rare  affection,  but  when  it  is  once  well  established  it  is 
practically  an  incurable  trouble. 

Excision  of  the  prostate  is  not  a  success;  castration  will 
only  check  the  progress  of  the  disease,  it  will  not  exterminate 
it;  perineal  section  is  but  a  temporary  makeshift,  and  there  is 
very  little  hope  from  internal  medication.  The  profession  has 
very  little  to  offer  for  the  relief  of  cancer  of  the  prostate. 
Some  slight  satisfaction  can  be  obtained  by  the  use  of  sounds, 
electricity,  massage,  rectal  work,  cold  water  and  internal  medi- 
cation. Every  measure  which  tends  to  improve  the  capillary 


ORIFIG1AL    SURGERY.  421 

circulation  of  the  prostate  will  prolong  the  fight  for  life,  but 
the  battle  will  ultimately  be  lost. 

Benign  affections  of  the  prostate  are  to  be  counted  among 
the  commonest  afflictions  to  which  men  are  liable.  Tumors, 
either  cystic  or  fibrous,  are  very  rare,  and  need  not  be  sep- 
arately considered,  as  their  removal  is  impracticable  except 
in  rare  cases,  and  the  measures  for  relief  are  similar  to  those 
which  are  effectual  in  the  two  commoner  forms  of  prostatic 
pathology,  namely,  atrophy  and  hypertrophy. 

One  word  about  fibroid  tumors  of  the  prostate.  If  the 
middle  lobe  be  enlarged  and  project  into  the  bladder  like  a 
rhinocerous  horn,  producing  painful  and  frequent  micturition, 
it  is  possible  by  suprapubic  cystotomy  to  successfully  excise 
the  offending  growth.  It  is  not  a  bad  plan  in  such  cases 
to  practice  perinea!  section  at  the  same  time,  so  that  the  up- 
per opening  in  the  bladder  can  be  closed  and  drainage  secured 
at  the  same  time.  Occasionally  a  fibroid  growth  will  project 
toward  the  rectum  from  one  of  the  lateral  lobes  of  the  pros- 
tate, or  it  sometimes  happens  that  the  middle  lobe  enlarges 
in  this  direction  instead  of  toward  the  bladder.  Where  the 
tumor  is  not  too  sessile  it  can  be  successfully  removed  by  an 
operation  from  below.  A  horseshoe  incision  is  to  be  made 
around  the  anus  parallel  with  the  outer  border  of  the  external 
sphincter.  The  sphincter  is  to  be  dissected  from  the  bed  of 
areolar  tissue  upon  which  it  rests  and  turned  toward  the  anus, 
but  not  injured.  The  rectum  is  then  to  be  dissected  loose  from 
the  under  surface  of  the  prostate  and  the  tumor  removed.  The 
disturbed  tissues  are  then  to  be  carefully  replaced  and  stitched 
into  position. 

Atrophy  and  hypertrophy  of  the  prostate,  however,  are 
the  conditions  which  will  by  far  the  most  frequently  apply  for 
relief.  Of  these  two  conditions,  hypertrophy  of  the  prostate 
has  received  a  fair  share  of  the  professional  attention  which  it 
deserves  because  of  the  urinary  disturbances  which  are  in- 
duced by  it.  But  atrophy  of  the  prostate,  although  perhaps 
the  commonest  form  of  pathology  which  the  prostate  takes  on, 
and  of  sufficient  consequence  in  chronic  diseases  of  men  to 
handicap  recovery  in  the  cases  in  which  it  is  a  factor,  is  almost 


422  ORIFIC1AL    SURGERY. 

invariably  overlooked,  as  the  patient  has  no  symptoms,  except 
possibly  that  of  impotency,  which  would  lead  the  doctor  to 
suspect  its  existence  and  suggest  an  examination  of  the  condi- 
tion of  the  prostate.  It  is  not  a  common  practice  for  physi- 
cians to  examine  the  condition  of  the  prostate  unless  some  in- 
dications of  prostatic  trouble  can  first  be  discovered  by  inter- 
rogating the  patient.  Atrophy,  however,  is  a  more  profound 
pathology  than  hypertrophy,  and  a  much  more  obstinate  af- 
fection to  cure ;  at  the  same  time  when  it  exists  it  is  a  matter 
of  vital  importance  that  the  condition  should  be  corrected  if 
possible.  Atrophy  of  the  prostate  is  a  frequent  precursor  of 
tuberculosis,  bone  disease,  spinal  cord  affections,  paresis,  and 
chronic  abscesses  in  various  parts  of  the  body. 

In  studying  the  treatment  of  atrophy  and  hypertrophy 
of  the  prostate  it  is  important  to  remember  one  fact  concerning 
the  sympathetic  nerve  distribution  of  the  pelvis,  and  that  is 
that  the  genito-urinary  organs  are  supplied  by  pencils  of  sym- 
pathetic plexuses  of  nerves,  which  are  common  in  their  ori- 
gin at  the  sympathetic  nerve  centres,  but  are  exceedingly  va- 
ried in  their  distribution.  As  the  brotherhood  of  nerves  which 
supply  the  bladder,  testicles,  urethra  and  prostate  spring  from 
the  same  nervous  centre,  the  various  parts  of  the  male  sexual 
and  urinary  systems  are  in  such  close  sympathy  that  the  irri- 
tation of  any  terminal  nerve  fibre  supplying  these  parts  may 
express  its  distress  in,  first  functional  derangement,  and  af- 
terward organic  pathology  of  any  of  the  parts  supplied  by 
other  branches  of  the  same  pencil  of  nerves.  I  mean  by  that 
that  a  narrow  meatus,  a  shortened  frgenum  and  narrow  or 
elongated  foreskin  may  induce  prostatic  congestion,  or  starva- 
tion, may  cause  prostatic  hyperesthesia  or  anesthesia,  accord- 
ing to  the  general  tendencies  of  the  patient.  The  influence 
which  the  rectum  exercises  over  prostatic  conditions  must  al- 
ways be  borne  in  mind,  for  the  outlets  of  the  body  which 
serve  for  the  exit  of  the  solid  and  liquid  excretions  are  also  in 
close  sympathy,  and  usually  enjoy  both  sickness  and  health  in 
common.  The  first  important  step,  therefore,  in  the  cure  of 
either  atrophy  or  hypertrophy  of  the  prostate  is  to  institute 
a  careful  examination  of  the  condition  of  the  parts  at  the  ex- 


ORIFIGIAL   SURGERY.  423 

tremity  of  the  penis  and  in  the  rectum.  If  the  meatus  is  too 
narrow  it  should  be  slit ;  if  the  condition  is  one  of  hyperspadias 
the  canal  should  be  reproduced ;  if  the  f raenum  is  so  short  as  to 
depress  the  point  of  the  penis  upon  extreme  retraction  of  the 
foreskin  it  should  be  clipped  and  the  extremity  of  the  penis 
liberated ;  if  the  opening  in  the  foreskin  be  too  small,  the  fore- 
skin itself  being  of  normal  length,  it  should  be  slit  along  the 
dorsum  sufficiently  to  give  perfect  freedom  of  motion  without 
constricting  the  glaiis  penis.  The  slit  in  such  cases  should  be 
carried  as  high  as  the  corona  glandis.  Where  the  fore- 
skin is  too  long,  even  if  it  is  not  too  narrow,  it  should 
be  amputated,  not  by  the  old  method  which  removed  the  en- 
tire foreskin,  for  this  does  not  seem  to  be  necessary,  but  suf- 
ficient to  relieve  the  redundancy  of  tissue,  so  that  in  a  relaxed 
condition  of  the  organ  the  corona  and  upper  one-half  of  the 
glans  is  covered,  leaving  only  the  lower  one-half  exposed. 
Urethral  sounds  should  be  passed,  using  soap  as  a  lubricant, 
because  by  this  means  the  urethra  can  be  relieved  of  any  ca- 
tarrhal  discharge  which  it  might  contain,  and  may  be  safely 
dilated  in  most  cases  to  No.  16  or  18,  English  scale.  Great 
care  should  be  taken  not  to  over-dilate  the  prostate,  as  it  is 
not  uncommon  to  induce  enuresis  by  the  use  of  sounds,  es- 
pecially in  those  well  advanced  in  life,  and  also  because  the 
prostate  is  somewhat  friable  and  over-dilatation  is  liable  to 
lacerate  it,  leaving  a  raw  surface  for  the  absorption  of  septic 
material.  Slight  rupture  of  the  prostate,  caused  by  the  care- 
less use  of  sounds,  is  a  common  cause  for  the  urethral  fever 
which  so  often  follows  their  use.  Whatever  form  of  rectal 
pathology  is  encountered  should  be  corrected,  be  it  hemor- 
rhoids, fistulas,  pockets  and  papillae,  ulcers  or  fissures,  or,  as  is 
sometimes  the  case,  merely  stenosis. 

There  is  a  very  close  nervous  connection  between  the  sig- 
moid  flexure  of  the  colon  and  the  prostatic  inch,  and  many 
cases  of  prostatic  trouble  defy  cure  simply  because  of  an  ir- 
ritable condition  of  the  sigmoid  flexure  of  the  colon,  which  has 
been  overlooked  and  is  an  active  agent  in  sustaining  the  pro- 
static  irritation. 


424  OElPIClAL    SURGERY, 

A  single  treatment  under  an  anesthetic  which  carries  out 
all  of  these  suggestions  is  frequently  sufficient  to  effect  a 
speedy  and  radical  cure  of  an  enlarged  prostate,  although  in 
most  cases  the  subsequent  and  periodic  use  of  sounds  and  the 
employment  of  sigmoid  and  rectal  treatments  at  stated  inter- 
vals aie  required  to  reduce  the  gland  to  its  normal  size. 

In  the  employment  of  sounds  it  is  better  to  use  them  heat- 
ed in  irritable,  hyperesthetic  and  spasmodic  conditions  of  the 
prostate  and  urethra,  whereas  cold  sounds  are  better  in  cases 
requiring  tonic  measures.  In  cases  exhibiting  irritable  ten- 
dencies if  sounds  are  employed  they  should  be  immediately 
removed  after  their  introduction.  But  where  the  parts  are 
pale,  anemic,  more  or  less  anesthetic,  and  therefore  calling  for 
stimulating  treatment  after  a  sound  has  been  introduced,  it 
may  be  held  carefully  in  position  for  ten,  fifteen  or  twenty 
minutes,  or  even  half  an  hour,  and  in  rare  cases  one  or  two 
hours.  It  is  better  to  underdo  than  overdo  their  use,  and  con- 
sequently the  length  of  time  for  a  sound  to  be  left  in  position 
can  only  be  ascertained  by  a  thorough  acquaintance  with  the 
case  under  treatment. 

Where  the  prostate  is  not  only  enlarged  but  irritable,  the 
use  of  rectal  plugs,  so  constructed  that  they  may  be  heated  by 
a  stream  of  hot  water,  is  invaluable,  and  may  be  employed 
daily  for  a  short  time  if  necessary,  although  once  or  twice  a 
week  is  usually  as  frequently  as  they  can  be  employed  to  ad- 
vantage. Electric  currents  can  be  used  in  the  urethra  and 
rendered  serviceable  in  reducing  or  developing  a  prostate,  ac- 
cording to  its  condition,  by  means  of  insulated  urethral  tips, 
upon  the  same  principle  that  similar  conditions  are  acted  upon 
by  electrical  treatments  in  other  parts  of  the  body,  the  gal- 
vanic current  aiding  absorption,  while  the  faradic  is  service- 
able in  strengthening  the  weakened  muscles  found  in  atonic 
conditions.  It  is  always  well  after  passing  sounds  to  imme- 
diately hold  the  point  of  the  penis  in  hot  water  for  one  or 
two  minutes  so  as  to  favor  a  prompt  reaction.  Massage  of  the 
prostate  is  serviceable  in  both  atrophy  and  hypertrophy,  but 
is  to  be  employed  with  extreme  caution  as  a  slight  bruising 
of  the  prostate  from  careless  massage  is  a  frequent  source 


ORIFIC1AL    SURGERY.  425 

of  cystitis  and  also  orchitis.  It  should  not  be  employed  often- 
er  than  once  or  twice  a  week,  and  even  then  with  extreme 
caution.  Water  may  be  employed  to  great  advantage  in  all 
forms  of  prostatic  pathology.  It  is  of  some  service  in  some  cases 
employed  in  the  rectum,  either  in  the  form  of  frequently  re- 
peated injections  in  small  quantities,  either  medicated  or  plain 
and  hot,  or  for  the  purpose  of  securing  dry  heat  by  the  aid  of 
a  rectal  plug.  And  in  the  urethra  it  is  often  serviceable  for 
purposes  of  irrigation,  especially  in  enlargement  of  the  pros- 
tate where  there  is  residual  urine.  But  its  greatest  service  is 
in  its  use  externally.  There  is  no  more  refreshing,  invigorat- 
ing or  curative  measure  known  to  doctors  than  the  skillful  use 
of  water  applied  to  the  base  of  the  body.  If  the  prostate  is  in 
an  irritable  condition  it  can  be  employed  either  as  a  hot  sitz 
bath  or  while  the  patient  is  placed  in  the  lithotomy  position 
by  means  of  a  pitcher  of  hot  water  poured  over  the  genital  or- 
gans, perineum  and  buttocks.  Where  a  tonic  effect  is  desired 
the  water  should  be  used  cold.  If  the  patient  is  very  weak  the 
action  of  the  cold  can  be  secured  by  first  douching  the  parts 
by  means  of  a  pitcher  of  very  hot  water  and  immediately  fol- 
lowing this  with  a  pitcher  of  ice  water.  The  parts  can  then 
be  dried  and  the  patient  either  dressed  or  put  into  bed  as  de- 
sired. If  the  patient  be  strong  enough  to  react  spontaneously 
from  the  use  of  cold  the  hot  water  had  better  not  be  em- 
ployed, and  for  such  cases  a  sitz  bath  of  cold  water  will  be 
found  very  satisfactory.  This  should  be  of  only  one  or  two 
minutes'  duration,  and  should  be  taken  at  bedtime,  after 
which  the  patient  should  get  into  bed  immediately  without 
drying  himself.  A  sitz  path,  which  includes  the  lower  half  of 
the  body  and  the  lower  extremeties,  is  still  more  serviceable 
for  those  who  are  sufficiently  vigorous  to  establish  a  satisfac- 
tory reaction.  In  some  cases  this  can  be  borne  only  every 
other  day,  while  a  few  can  stand  a  daily  treatment  of  this  kind 
to  advantage. 

So  much  for  physics.  And  now  for  a  briefer  word  upon  a 
still  more  important  consideration  in  the  treatment  of  pro- 
static  cases.  As  the  body  is  but  the  crystallized  life,  so  its 
diseases  are  but  the  result  of  unfortunate  mental  and  emo- 


426  ORIFICTAL    SURGERY. 

tional  habits.  The  use  of  the  handkerchief  does  not  cure  the 
catarrh,  and  the  removal  of  disease  products  in  the  prostatic 
region  by  surgical,  medical  or  hygienic  means  is  mere  patch- 
work and  but  temporizing  with  decay  unless  the  habits  of 
thought  and  feeling  which  have  permitted  the  prostatic  disin- 
tegration to  take  place  be  also  reconstructed  and  turned  into 
healthier  channels  of  activity. 

In  medical  writings  it  is  customary  to  confine  the  atten- 
tion to  the  mere  physical  forms  of  disease,  ignoring  the  part 
which  internal  forces  play  in  their  establishment.  But  the 
time  has  now  come  when  we  should  no  longer  be  guilty  of  so 
serious  an  omission,  for  as  the  whole  body  is  but  the  crystal- 
lization of  its  internal  life,  it  stands  to  reason  that  any  attempt 
to  effect  a  permanent  cure  by  physical  agencies  alone  is  but 
born  of  ignorance  and  fostered  by  professional  habit.  In  this 
day  of  freedom  we  must  emancipate  ourselves  from  the  thral- 
dom of  preconceived  notions  and  refuse  longer  to  be  handi- 
capped by  the  narrow-minded  precepts  formulated  by  those 
who  are  spiritually  blind.  Our  mission  is  to  cure  the  sick,  and 
this  can  only  be  done  by  a  re-establishment  of  order  in  men- 
tal and  emotional  habits  as  well  as  in  physical  functions.  The 
whole  man  is  our  patient,  and  mere  physical  consideration  is 
not  adequate  to  the  cure  of  morbid  physical  conditions,  espe- 
cially of  the  prostate. 

My  paper  is  already  of  sufficient  length  for  the  present 
occasion,  and  the  theme  now  broached  is  of  such  importance 
that  I  shall  make  no  effort  to  do  more  than  merely  record  my 
hearty  appreciation  of  the  important  bearings  which  the  life 
of  the  body  has  upon  the  body  itself.  The  cure  of  love  which 
has  been  sick,  even  unto  lust,  in  all  forms  of  prostatic  derange- 
ment both  functional  and  chronic,  is  a  sufficient  theme  in  it- 
self for  an  extensive  paper  which  should  be  written  and  I 
promise  you  shall  be  written  in  the  near  future.  When  lust 
has  consumed  the  sexual  organs  it  is  because  love  has  been  sick, 
and  the  relief  from  lust  and  its  ravages  lies  in  the  re-establish- 
ment of  love  in  all  the  strength  of  its  natural  prerogative. 
There  is  a  thoroughly  accurate,  effective  and  scientific  way  of 


ORIFIG1AL    SURGERY.  427 

accomplishing  this  magical  transformation  in  human  emotions ; 
and  although  the  present  is  not  the  time  for  its  consideration 
I  should  be  untrue  to  this  society,  to  the  subject  under  dis- 
cussion, and  to  myself  if  while  discussing  the  subject  from  a 
material  standpoint  I  should  not  also  recognize  that  the  cure 
of  prostatic  difficulties  involves  mental  and  emotional  trans- 
formations as  well  as  physical  patchwork. 


SECTION  VII. 


The  Female 
Sexual  Organs. 


ORIFIG1AL    SURGERY.  431 


CHAPTER  LVIL 


SOME  POINTS  CONCERNING  THE  ANATOMY  AND 
PHYSIOLOGY  OF  THE  FEMALE  ORGANS. 


E.   H.   PRATT,   M.   D. 


The  nervous  supply  of  the  clitoris  and  its  hood,  in  the 
female,  corresponds  with  that  of  the  point  of  the  penis  and  the 
foreskin  in  the  male.  The  nerves  which  furnish  the  labia 
minora  are  the  same  which,  in  the  male,  supply  the  scrotum. 
The  nerves  which  are  distributed  to  the  ovaries  and  Fallopian 
tubes  in  the  female,  are  the  same  ones  which,  in  the  male,  go 
to  the  testicles;  while  the  nervous  distribution  to  the  uterus 
corresponds  to  those  which  are  distributed  to  the  prostate 
gland. 

In  the  male,  the  urinary  and  sexual  organs  are  so  inter- 
mingled that  the  first  inch  of  the  urethra,  which  carries  the 
urine  from  the  bladder,  passes  directly  through  the  prostate 
gland,  which  is  the  great  nerve  centre  for  the  male  sexual  or- 
gans. In  the  female,  the  sexual  and  urinary  tracts  are  divorced, 
the  female  urethra  being  short  and  uncomplicated  by  any  di- 
rect connection  with  the  uterus.  The  nervous  connection, 
however,  remains  the  same ;  and  as  prostatic  conditions  affect 
the  condition  of  the  bladder  and  urethra,  and  are  reflected  at 
the  end  of  the  penis,  where  they  can  be  more  or  less  correctly 
interpreted,  so  uterine  conditions,  especially  those  at  the  in- 
ternal os,  may  express  themselves  in  bladder  and  urethral 
language. 

Idiopathic  cystitis  and  urethritis  in  the  female  are  rare 
affections.  Reflected  troubles,  however,  from  uterine  pathol- 
ogy are  exceedingly  common.  In  the  male,  bladder  and  ureth- 
ral troubles  usually  begin  with  some  form  of  prostatic  derange- 
ment, and  the  cure  of  the  one  involves  attention  to  the  other. 
In  the  female,  vesicular  and  urethral  difficulties  can  scarcely 
be  cured  without  respecting  the  association  which  exists  be- 
tween the  uterus,  clitoris,  hymen  and  urethra. 


432  ORIFIGIAL    SURGERY. 

Of  course,  in  both  sexes,  it  is  necessary  to  remember  that 
nature's  philosophy  is  orificial,  and  that  the  lower  openings  of 
the  body  are  mutually  interested  in  each  other's  welfare.  It 
is  impossible  to  maintain  normal  urethral  and  sexual  condi- 
tions in  either  sex  when  rectal  pathology  is  present;  and  it 
is  also  impossible  to  maintain  a  rectum  in  a  normal  state  so 
long  as  the  sexual  and  urethral  abnormalities  remain  uncor- 
rected. 

Never  forgetting,  therefore,  that  the  pelvic  organs  are 
supplied  by  a  pencil  of  sympathetic  nerve  filaments,  so  inti- 
mately associated  that  the  condition  of  one  of  them  influences, 
and  oftentimes  expresses  itself  by  means  of  any  or  all  of  the 
other  filaments,  let  us  consider  a  few  points  in  the  anatomy 
and  physiology  of  the  individual  organs  of  the  female  sexual 
system. 

The  same  points,  which  were  observed  in  reference  to  the 
foreskin  of  the  penis,  apply  to  the  hood  of  the  clitoris.  The 
normal  hood  exposes  the  point  of  the  clitoris,  is  readily  re- 
tracted, and  does  not  bind,  either  when  pendant  or  retracted. 
If  enlongated  or  hypertrophied,  it  should  be  amputated;  ifc 
atrophied  and  stenosed,  it  calls  for  a  mere  slitting  along  the 
dorsum  to  relieve  the  abnormal  tension. 

The  hood  of  the  clitoris  differs  from  the  foreskin  in  one 
respect,  that  it  does  not  completely  surround  the  clitoris,  simply 
covering  the  clitoris  like  a  gabled  roof.  As  the  point  of  the 
penis  is  the  most  sensitive  spot  of  the  male  sexual  organs,  so 
the  clitoris  acts  in  a  like  capacity  for  the  female  sexual  or- 
gans. An  adhesion  of  the  hood  of  the  clitoris  to  the  clitoris  is 
as  mischievous  in  the  female  economy  as  the  adhesion  of  the 
foreskin  to  the  glans  penis  is  in  the  male. 

It  is  exceedingly  common  to  find  the  hood  of  the  clitoris 
adherent  to  the  clitoris  and  confining  smegma  which  has  been 
unmolested  for  a  lifetime,  even  in  subjects  well  along  in  years. 
When  one  thinks  of  the  convulsions,  the  dropsies,  the  epilep- 
sies, the  paralyses,  the  insomnia,  the  dyspepsia,  the  eczema, 
the  strabismus,  the  kidney  troubles,  and  the  immorality  which 
date  their  beginnings  from  abnormalities  of  the  foreskin,  and 
realize  that  the  clitoris  and  its  hood  are  supplied  by  identically 


OKIFICIAL    SURGERY. 


433 


the  same  set  of  nerves,  subject  to  the  same  laws  of  action  and 
reaction,  and  that  abnormalities  of  the  hood  of  the  clitoris 
are  as  mischievous  as  those  of  the  foreskin;  and  realize,  also, 


FIG.  l.  FIG.  2.  K 

TAKEN  FROM  AM.  JOURNAL  OF  OBSTETRICS. 

Fig.  1.    Miss  A.    Prepuce  firmly  adherent  to  glans,  allowing  only  the  tip  of  the 
glans  to  protrude,  and  imprisoning  small,  hard  particles  of  smegma. 
Fig.  2.    Miss  A.    Prepuce  stripped  from  glans. 


Fro.  3. 


Fro.  4. 


Fig.  3.  Miss  B.  A  deceptive  case.  Glans  apparently  free  on  casual  Inspection, 
but  its  base  tightly  adherent  with  prepuce,  and  inspissated  smegma  retained.  Prep- 
uce drawn  up  as  far  as  possible. 

Fig.  4.    Miss  B.    Adhesions  separated  and  prepuce  drawn  up. 

that  doctors  have  for  generations  completely  ignored  the  part ; 
it  is  easy  to  understand  why  the  true  history  of  the  treatment 
of  diseases  of  women  is  marred  by  the  record  of  so  many  fail- 


434  ORIFICIAL    SURGERY. 

ures;  the  chlorosis  and  the  insanity,  the  organic  derangements 
and  the  susceptibility,  the  various  forms  of  mal-nutrition,  and 
the  mental  and  moral  eccentricities  of  the  gentler  sex  are  eas- 
ily understood.  The  miseries  that  have  been  entailed  upon 
the  females  of  our  race  by  what  doctors  have  not  done,  in  the 
way  of  simply  removing  all  forms  of  irritation  from  the  cli- 
toris and  its  hood,  if  written,  would  make  a  long  and  mourn- 
ful page  in  medical  history. 

Many  years  ago,  the  French  doctors  recognized  the  cli- 
toris as  a  source  of  nerve  waste  in  women.  Their  measures 
for  relief  were  so  radical  as  to  do  serious  harm  instead  of  the 
good  intended.  In  cases  where  the  condition  of  the  clitoris  was 
recognized  as  a  source  of  irritation,  they  were  in  the  habit  of 
amputating  the  labia  minora,  the  hood  of  the  clitoris,  and  the 
clitoris  itself.  If  they  had  practiced  the  same  philosophy  upon 
the  male  sex,  for  the  relief  of  troubles  which  arose  from  the 
irritation  of  the  foreskin,  they  would  have  amputated  the 
penis  and  scrotum  as  well.  The  result  of  their  severe  work 
was  not  only  a  relief  from  the  abnormal  irritation  which  they 
sought  to  cure,  but  also  from  all  normal  sexual  instincts,  and 
was  so  frequently  followed  by  insanity,  that  the  question  of 
the  practice  was  subject  for  legislative  action,  and  the  ampu- 
tation of  the  pudenda  was  forbidden  by  law,  making  one  of 
the  most  painful  pages  in  the  history  of  French  legislation. 

It  is  no  more  necessary  to  amputate  a  normal  clitoris  than 
it  is  a  normal  penis ;  and  it  is  quite  as  essential  for  the  mainte- 
nance of  female  health  to  secure  and  maintain  in  normal  con- 
dition the  hood  of  the  clitoris,  as  it  is  essential  for  male  health 
to  secure  and  preserve  a  normal  condition  of  the  foreskin. 

Although  in  the  present  article,  it  is  not  intended  to  pre- 
sent the  subject  of  treatment,  it  might  be  well  to  mention  in 
the  present  connection  that  in  amputating  the  hood  of  the 
clitoris,  it  should  not  be  done  too  closely;  sufficient  room 
should  be  left  to  admit  the  stitching  of  the  membrane  which 
lines  the  hood  to  the  skin  which  covers  it,  so  that  when  the 
parts  heal  the  clitoris  will  not  be  unduly  bound  down  by 
cicatricial  formations. 


ORIFIClAL   SURGERY.  43? 

Nature  is  consistent  in  her  building  of  the  human  house, 
and  seems  to  distribute  individual  characteristics  with  equal 
generosity  in  parts  which  are  closely  associated  in  function. 
I  mean  that  those  which  present  hypertrophy  of  the  hood  of 
the  clitoris,  will  be  equally  generous  with  the  tissue  about  the 
orifice  of  the  vagina,  in  the  structure  of  the  uterus,  and  in  the 
construction  of  the  rectum. 

The  cases,  therefore,  which  call  for  a  removal  of  the  hood 
of  the  clitoris,  will  frequently  demand  considerable  trimming 
of  the  urethra  and  hymen,  present  a  hypertrophied  cervix  and 
body  of  the  uterus,  and  also  more  or  less  redundancy  of  tissue 
in  the  rectum.  Those  which  are  atrophied  in  one  of  these  parts 
are  more  or  less  atrophied  in  the  others.  The  cases  which  pre- 
sent a  fringe  of  papillary  elongations  about  the  urethra  and 
on  the  inner  margins  of  the  hymen,  will  also  be  furnished  with 
uterine  granulations  and  rectal  pockets  or  papillae,  or  both, 
just  as  though  an  abnormal  condition  of  one  of  these  parts 
had  been  contagious  and  imprinted  its  characteristics  on  all 
the  others. 

If  the  orifice  of  the  vagina  and  the  cervix  uteri  are  in  a 
normal  condition,  the  stretch  of  vagina  which  connects  them 
will  also  be  normal.  But  when  pathology  has  enthroned  it- 
self at  the  two  extremities  of  this  canal,  the  canal  itself  often- 
times suffers  throughout  its  entire  extent. 

A  normal  vagina  is  perfectly  smooth,  dilatable,  but  neither 
baggy  nor  cavernous,  moistened  with  a  proper  amount  of  mu- 
cus ,but  not  to  the  extent  of  deserving  the  title  of  leucorrhoea. 

When  the  passages  from  the  uterine  cavity  have  been  ex- 
coriating, especially  in  cases  which  present  fringe-like  ex- 
crescences about  the  hymen  and  the  urethra,  and  have  re- 
mained uncorrected  for  a  considerable  length  of  time,  the 
whole  vagina  becomes  abnormally  congested  and  frequently 
presents  an  abnormal  development  of  the  papillae  of  its  mucous 
membrane,  which  oftentimes  becomes  so  rough  and  hard  as  to 
present  the  roughened  appearance  and  feel  of  a  fish's  maw. 
This  condition  is  sometimes  so  extreme  as  to  call  for  the  use  of 
the  curette  and  scissors  over  more  or  less  of  the  entire  surface 


438 


ORlFIGlAL    StJBGERY. 


of  the  vagina.  Dilatation,  proper  medication,  and  completed 
orificial  work  are  sufficient  to  restore  the  mucous  membrane 
to  its  normal  velvety  texture. 

The  external  os  uteri  should  point  slightly  backwards, 
present  the  same  color  as  the  vaginal  mucous  membrane,  and 
be  patulous  and  dilatable  to  pass  from  a  No.  9~y2  to  14,  English 


FIG.  7. 


FIG.  8 — TAKEN  FROM  LUSK. 


Fig.  7,  1,  cavity  of  the  body ;  2,  lateral  wall;  3.  superior  wall;  4.4.  cornua;  5,  os 
intern um;  6,  cavity  of  the  cervix ;  7,  arbor  vitae  of  the  cervix;  8,  os  internum;  9,  9, 
vagina. 

Fig.  8.  1,  body;  2,  2,  angles;  3,  cervix;  4,  site  of  os  internum;  5.  vaginal  portion 
of  the  cervix;  i>,  external  os:  7,  7,  vagina. 

scale,  uterine  sound  without  resistance.  The  deviations  from 
this  standard,  like  those  of  the  other  parts  under  considera- 
tion, are  those  of  atrophy  and  hypertrophy,  hyperaesthesia  and 
anaesthesia  in  their  various  forms  and  degrees  of  manifesta- 
tion. 

The  external  appearance  of  the  cervix  uteri,  however,  may 
be  normal  in  every  particular  and  still  enclose  in  its  grasp 
mischievous  forms  of  pathology  in  the  mucous  membrane  lin- 
ing its  canal ;  so  that  an  examination  of  the  uterus  is  not  com- 
plete without  a  thorough  exploration  of  its  cavity,  perfectly 
regardless  of  its  position  and  external  appearance. 


ORlFIClAL   SURGERY.  438 

The  internal  os  is  the  lower  opening  of  the  uterus  proper, 
and  is  guarded  by  circular  fibres  of  the  body  of  the  uterus. 
Its  tissues  are  independent  of  those  of  the  cervix.  The  cervix 
is  attached  by  muscular  and  aerolar  fibres  to  the  body  of  the 
uterus  after  the  manner  that  the  basket  of  a  balloon  is  at- 
tached to  its  gas  bag  by  the  series  of  ropes  which  pass  around 
the  outside  of  the  balloon. 

The  internal  os  is  the  last  gateway  which  guards  the 
cradle  of  the  race,  and  is  consequently  the  most  vital  point  of 
the  female  sexual  system.  It  is  the  great  nervous  centre  which 
dominates,  more  than  any  other  one  spot,  the  condition  of  the 
entire  female  sexual  apparatus.  The  messages  from  this  cen- 
tral office  pass  upward  to  the  uterine  cavity,  and  outward  to 
the  Fallopian  tubes,  with  their  fimbriated  extremities  ana  the 
ovaries.  They  pass  downward  and  fluctuate  the  condition  of 
the  cervical  canal  and  the  external  os.  Their  influence  extends 
still  farther  by  means  of  other  terminal  nerve  fibres,  and  af- 
fects the  condition  of  the  orifice  of  the  urethra  and  the  puden- 
da in  all  its  parts,  including  the  clitoris.  They  also  have  di- 
rect telephonic  communication  with  the  sigmoid  flexure  of  the 
colon,  and  with  the  last  inch  of  the  rectum. 

Above  all  other  questions,  therefore,  in  the  economy  of 
the  female  sexual  organs,  is,  what  is  the  state  of  the  internal 
os  uteri  ?  Is  it  stenosed  or  too  patulous,  is  it  hypertrophied  or 
atrophied,  is  it  hypergesthetic  or  anaesthetic,  is  it  free  or 
choked  by  undue  flexion  of  the  organ  forward  or  backward? 
It  is  the  most  fixed  part  of  the  utrerus,  and  circulating  about 
it  are  the  largest  nerve  trunks  and  the  largest  lymphatics.  It 
is  the  great  commercial  center  of  sexual  activity,  and  upon  its 
health  or  disease  depends  the  female  harmony  and  discord. 

The  last  orifices  in  this  line  of  investigation  are  the  uter- 
ine orifices  of  the  Fallopian  tubes.  Health  of  these  openings 
means  normal  Fallopian  tubes  and  ovaries.  The  converse  of 
this  is  also  true,  that  morbid  states  of  ovary  and  Fallopian 
tubes  have  their  incipiency  in  pathological  states  of  these 
openings. 

When  these  openings  have  undergone  pathological 
changes,  the  measures  which  establish  a  healthy  endometrium 


440 


ORIFIG1AL   SURGERY. 


generally  are  about  all  that  can  be  relied  upon  to  exterminate 
it.  The  curette,  the  douche,  the  packing,  electricity,  dilatation, 
and  internal  medication  in  addition  to  the  effects  which  can 
be  produced  by  attention  to  the  other  terminal  nerve  fibres  of 


FIG.  9.— FROM  AMERICAN  TEXT-BOOK  OF  SUKGEKV. 

Diagrammatic  Sagittal  Section  of  the  Female  Pelvis:  U,  uterus;  E,  Rectum;  S 
symphysis;  P,  perineal  body ;  B  is  beneath  bladder.  This  is  the  position  of  the  uterus 
when  the  bladder  is  almost  empty. 

the  genitalia,  together  with  what  may  be  obtained  from  cor- 
rect habits  of  thinking  and  feeling,  constitute  the  various 
means  of  relief  which  the  profession  has  to  offer  for  disordered 
conditions  of  the  internal  openings  of  the  Fallopian  tubes. 

If  tubular  and  ovarian  pathology  has  been  well  established 
and  too  far  advanced  to  react  from  these  measures,  the  case 


ORIFIG1AL   SURGERY.  441 

has  gone  beyond  the  reach  of  orificial  work,  and  appeals  as  a 
last  resort  to  the  laparotomist. 

It  may  strike  some  thoughtful  reader  as  incongruous,  in 
an  article  which  essays  the  mention  of  a  few  anatomical  and 
physiological  facts  about  the  female  sexual  organs,  to  occupy 
so  much  space  with  the  deviations  from  the  normal  standards 
of  excellence  in  these  parts,  rather  than  being  content  with 
purely  anatomical  and  physiological  considerations.  The  fact 
of  the  matter  is,  that  should  one  enter  upon  a  search  for  nor- 
mal conditions  of  the  sexual  organs  of  the  female,  the  chances 
are  that  one  will  almost  always  encounter  pathology  instead 
of  anatomy;  and  that,  consequently,  physiological  processes 
are  as  disordered  and  sick  as  the  anatomical  conditions  which 
shape  them.  This  is  true  even  with  the  apparent  specimens 
of  health  that  are  proud  of  their  independence  of  the  medical 
fraternity. 

Professional  cannibals  are  a  savage  looking  race;  pro- 
fessional shepherds  have  crystallized  their  habitual  kindness 
into  features  which  tell  their  own  story  of  gentleness  and  ten- 
derness. There  are  intellectual  races  and  savage  races,  there 
are  musical  races  and  warlike  races,  and  in  every  race  the  in- 
ternal life  is  so  stamped  on  the  external  as  to  leave  its  im- 
print indelibly  impressed  into  the  forms  of  flesh ;  but  there  is 
one  element  of  human  nature  possessed  by  all  races  of  men 
which  has  made  discordant  music  upon  the  harp  of  life  through 
all  history.  Distorted  sexual  appetites  have  tinctured  human 
love  with  its  perversion  of  lust  during  all  the  preceding  ages, 
until  the  unwritten  history  of  the  inner  lives  of  men  would 
make  the  largest  and  most  melancholy  library  on  earth.  I 
said  unwritten  history.  To  those  who  can  read  the  rocks,  the 
evolution  of  the  earth  is  a  plain  page,  for  the  story  of  animal 
and  vegetable  life  is  crystallized  into  them;  and  to  those  who 
can  correctly  interpret  the  human  body  and  its  crystallized 
forms,  which  are  but  the  imprint  of  generations  of  living,  the 
history  of  man's  inner  life  is  readily  interpreted. 

Passions  of  all  kinds,  when  they  have  become  perpetual 
habits  through  succeeding  generations,  invariably  clothe  them- 
selves in  bodily  forms  of  expression ;  and,  judged  by  this 


442  ORIPIC1AL    SURGERY. 

standard,  the  female  sexual  organs  (and  the  male  as  well)  tell 
a  sad  story  of  perverted  sexual  emotions.  Undoubtedly,  the 
abnormal  physical  conditions  which  we  inherit,  and  which  are 
encountered  in  almost  every  human  being,  react  upon  the  na- 
ture of  the  individual  and  prescribe  its  tendencies  to  develop- 
ment. Only  when  such  abnormalities  are  removed  and  the 
forms  are  restored  to  their  ideal  condition,  can  we  hope  for 
that  immunity  from  temptation  that  is  essential  to  true  health 
and  happiness. 

Orificial  work  will  be  necessitated  for  both  sexes  through 
many  generations  to  secure  for  mankind  the  inheritance  of 
their  untarnished  birthright,  which  gives  them  sexuality  and 
not  sensuality,  which  inspires  them  with  love,  but  does  not 
consume  them  with  lust.  It  is  said  concerning  dogs  that  if  the 
tails  of  both  sexes  be  amputated  close  to  the  body  through  sev- 
eral generations,  it  will  result  in  a  tailless  species.  If  Moses 
had  prescribed  the  amputation  of  the  hood  of  the  clitoris  as 
well  as  the  removal  of  the  foreskins  for  the  Jews,  they  would 
undoubtedly  by  this  time  have  had  the  qualities  which,  crys- 
tallized, produce  these  formations,  so  thoroughly  eradicated 
from  their  natures  that  the  forms  themselves  would  have  dis- 
appeared, and  the  Jews  to-day  would  be  born  without  fore- 
skins and  without  hoods  to  the  clitoris.  It  is  not  uncommon,  I 
am  told,  even  as  it  is,  with  the  practice  of  circumcision  con- 
fined to  one  sex,  to  encounter  Jewish  male  children  who  are 
born  without  a  foreskin. 

I  do  not  pretend  to  say  that  an  ideal  condition  of  the 
sexual  organs  involves  an  absence  of  foreskin  or  the  hood  of 
the  clitoris.  The  abnormal  states  of  humanity  have  existed  so 
long  that  pathology  has  become  anatomy  and  distorted  func- 
tions have  become  physiology  and  sickness  seems  to  be  the 
normal  state  of  the  human  race ;  and  it  will  be  difficult  to  de- 
cide upon  the  true  standard  of  ideal  excellence.  The  present 
state  of  these  organs  as  found,  however,  is  so  extremely  and 
evidently  abnormal,  that  a  systematic  and  persistent  attack 
upon  the  present  abnormalities  which  prevail  is  unquestion- 
ably not  only  advisable  but  exceedingly  desirable.  From  re- 
sults obtained  in  the  practice  of  orificial  surgery,  we  simply 


ORIFICIALi   SURGERY. 


443 


444  ORIPIC1AL   SURGERY. 

know  that  the  putting  of  these  parts  in  better  form  does  con- 
serve the  power  of  the  sympathetic  nerve,  does  remove  ab- 
normal sexual  inclinations,  does  free  the  individual  from  un- 
happy emotional  suggestions,  does  liberate  the  soul  from  its 
thraldom  of  unholy  desire,  does  economize  nerve  force,  and 
does  increase  thereby  the  general  re-active  power  of  the  sys- 
tem ;  thus  securing  for  it  increased  peristaltic  actions  through- 
out the  body,  thus  enabling  it,  when  its  functions  are  disor- 
dered, and  when  it  is  staggering  under  pathological  loads,  to 
regain  its  equilibrium,  and  enjoy  once  more  the  harmony  and 
pleasure  of  normal  bodily  functions  in  general  and  in  detail. 

From  this  it  would  appear  that  the  hopes  of  the  race  for 
emancipation  from  sin  as  well  as  from  sickness  will  find  their 
main  reliance  in  orificial  surgery. 

Sexual  abnormalities  have  failed  to  receive  their  due  meed 
of  attention  at  the  hands  of  the  profession,  because  as  they 
were  extravagant  of  sympathetic  power  rather  than  cerebro- 
spinal,  they  did  not  appeal  to  the  consciousness  of  patients. 

The  cuts  which  are  dispersed  throughout  the  present  arti- 
cle are  introduced  simply  to  refresh  the  minds  of  the  readers 
on  the  anatomy  of  the  parts  discussed  and  to  ensure  a  clear 
understanding  of  what  has  been  written. 

CHAPTER  LVIII. 


TERMINAL  NERVES  OP  THE  SYMPATHETIC  AND  THEIR 
TROUBLES  AS  A  FACTOR  IN  PELVIC  INFLAMMA- 
TIONS AND  OTHER  DISORDERS  OF  WOMEN. 


E.   H.   PRATT,   M.   D. 


The  physiological  world  has  long  been  deeply  concerned 
about  the  two  nervous  systems,  the  cerebro-spinal  and  sympa- 
thetic, and  interest  in  the  subject  is  increasing.  Many  prob- 
lems in  connection  with  the  study  still  remain  unsolved,  and 
yet  there  is  much  knowledge  upon  the  subject  which  is  now 
well  established.  In  a  general  anaylsis  of  our  human  organ- 


ORIFIC1AL   SURGERY.  445 

ization  no  one  will  question  that  it  possesses  a  conscious  and 
an  unconscious  part.  The  conscious  part  is  perpetually  in 
evidence,  sensing  in  manners  peculiar  to  itself  its  surrounding 
panorama  of  other  existences  and  conditions  and  directing  the 
activities  of  the  body  so  far  as  it  can  control  them  according- 
ly. No  one  can  question  the  fact  that  the  physical  habitation 
of  the  conscious  human  being  is  the  cerebro-spinal  system, 
which  consists  of  the  brain,  spinal  cord,  and  their  afferent  and 
efferent  nerves.  But  there  is  also,  as  everyone  knows,  an  un- 
conscious or  sub-conscious  part  of  us,  whose  earthly  abiding 
place  is  unquestionably  in  the  sympathetic  system  of  nerves, 
which  consist  of  ganglia  of  gray  matter  and  of  afferent  and 
efferent  nervous  cords  connected  therewith. 

Our  conscious  selves  are  more  or  less  intelligent  and  ra- 
tional; our  unconscious  selves  are  automatic  and  more  or  less 
mechanical  in  their  activities.  Between  these  two  forms  of  us 
there  is  a  very  close  relationship,  whether  viewed  physically 
or  physiologically.  And  yet,  while  they  have  much  in  com- 
mon, each  has  spheres  of  operation  perfectly  independent  of 
the  other.  It  is  perfectly  natural  that  the  conscious  part  of 
us  and  its  earthly  house,  the  cerebro-spinal  system,  should  have 
monopolized  the  lion's  share  of  attention  and  consideration 
in  the  deliberations  of  medical  men,  for  by  nature  it  is  con- 
spicuous and  self-assertive,  and  how  we  feel  or  sense  ourselves 
to  be,  is  easily  taken  to  be  synonymous  with  how  we  are.  For 
in  this  world  of  signs,  appearances  are  perpetually  parading 
themselves  as  realities. 

But  our  unconscious  part,  whose  physical  lodging-place 
is  the  sympathetic  nerve,  is,  especially  of  late  years,  assum- 
ing its  proper  position  of  importance  because  we  now  realize 
how  much  it  has  to  do  with  the  formation  of  our  physical  his- 
tory. The  sympathetic  nerve  as  a  factor  in  health  and  in  dis- 
ease is  now  beginning  to  receive  scientific  consideration  in 
the  etiology  and  treatment  of  all  the  various  forms  of  devia- 
tions from  health  to  which  physical  man  is  prone. 

There  is  a  book  recently  published  by  Dr.  Byron  Robinson, 
of  Chicago,  upon  the  sympathetic  nerve.  The  book  is  called 
"The  Abdominal  Brain  and  Automatic  Visceral  Ganglia."  Per- 


446  ORIF1C1AL    SURGERY. 

mit  me  to  quote  briefly  from  a  page  of  this  book  a  few  sentences 
bearing  upon  the  mutual  relationships  and  functions  of  the  two 
nervous  systems.  On  page  8  Dr.  Robinson  states  that  ' '  The  ce- 
rebro-spinal  nerves  together  perform  the  animal  functions 
which  prove  us  to  be  feeling  and  thinking  and  willing  beings." 
That  is,  the  physical  products  of  cerebro-spinal  activity  are 
purely  conscious  products.  We  think,  we  feel,  we  decide,  we 
will,  and  then  we  become.  It  is  quite  evident  from  this  that 
all  products  of  our  conscious  living  not  only  require  correction 
when  they  become  unsatisfactory,  but  that  radical  work  in- 
volves education  as  well,  for  habits  of  thought  and  feeling  can 
be  corrected  by  education  and  by  education  only,  here  being 
unquestionably  the  legitimate  field  for  suggestive  therapeutics. 

Immediately  following  the  sentence  quoted  occurs  the  fol- 
lowing paragraph :  ' '  The  ganglionic  system  of  nerves,  with  the 
abdominal  brain  as  their  central  organ,  performs  the  vital 
functions  which  are  independent  of  mind  and  present  to  .us  the 
idea  of  life.  The  sympathetic  system  of  nerves  presides  over 
the  viscera — over  secretion,  nutrition,  gestation,  expulsion, 
respiration,  and  circulation — over  sub-conscious  phenomena." 
In  other  words,  growth  and  repair  are  all  dominated  by  the 
sympathetic  nerve.  To  a  disturbed  and  inadequate  supply  of 
nerve  force  must  all  deviations  from  the  health  standard  be 
attributed,  and  to  this  same  power  must  all  remedial  measures 
for  their  effectiveness  appeal. 

As  Dr.  Robinson's  position  is  merely  that  which  is  uni- 
versally recognized  by  all  prominent  anatomists  and  physiolo- 
gists, it  certainly  behooves  us  as  physical  tinkers  of  this  watch 
of  time,  the  human  body,  to  bear  in  mind  the  construction  of 
its  machinery,  and  in  inaugurating  curative  measures  have 
due  respect  to  the  waste  and  repair  of  the  sympathetic  nerve. 
The  existence  of  pelvic  pathology,  in  common  with  physical 
disorders  of  the  general  system  wherever  located,  implies, 
therefore,  a  deranged,  depleted,  or  otherwise  disturbed  sympa- 
thetic nerve  force.  Our  work  of  physical  adjustment  and  re- 
lief is  consequently  incomplete  unless  the  sympathetic  dis- 
turbances which  were  their  first  cause  be  sought  for  and  cor- 
rected as  far  as  possible. 


OBIFIG1AL   SURGERY.  447 

With  this  fact  in  mind,  let  us  briefly  consider  the  waste 
and  repair  of  sympathetic  nerve.  First,  the  waste.  Sympa- 
thetic nerve  force  is  usually  wasted  or  its  rhythm  disturbed 
in  either  one  of  three  ways:  First,  by  undue  terminal  nerve 
impingement ;  second,  by  excessive  and  unremitting  demands 
upon  the  sympathetic  nerve  supply  to  the  involuntary  mus- 
cles; third,  by  impingement  or  undue  pressure  of  the  sympa- 
thetic nerve  trunks  themselves. 

First:  Undue  terminal  nerve  impingement.  In  consid- 
ering this  point,  it  is  well  to  remember  that  the  sympathetic 
nerve  supplies  an  apparatus,  not  by  a  single  nerve  trunk,  but 
by  a  pencil  of  nerves  proceeding  from  a  common  source,  and 
that  impingement  of  any  one  of  the  terminal  nerve  fibres,  by 
disorganizing  the  sympathetic  harmony  at  the  nerve  center, 
can  throw  into  disordered  operation  any  or  all  of  the  other 
fibres  proceeding  from  the  same  source. 

Gynecologists  will  be  specially  interested  in  the  pencil  of 
nerves  which  supplies  the  pelvic  organs  of  women.  From  the 
same  nerve  centers  plexuses  of  the  sympathetic  pass  to  the 
ovaries,  to  the  fallopian  tubes,  to  the  uterus,  to  the  vagina,  to 
the  vulva,  to  the  bladder,  to  the  urethra,  to  the  clitoris,  and  to 
the  rectum,  thus  associating  all  these  parts  in  close  sympa- 
thetic relation. 

Impingement  of  the  terminal  nerve  fibres  which  pass  to 
the  ovaries  may  take  place  in  either  of  two  ways:  First,  ci- 
catricial  contraction  of  roughened  apertures  occasioned  by 
the  discharge  of  the  ovum  in  the  tunic  of  the  ovary.  Most  of 
the  scars  thus  produced  are  harmless,  but  occasionally  the  mar- 
gins of  the  wound  do  not  heal  symmetrically  and  the  conse- 
quent impingement  and  strangulation  of  tissue  ensues.  It  is 
not  at  all  uncommon  to  encounter  spots  of  hardened  cicatricial 
tissue  in  one  or  more  places  upon  one  or  both  ovaries. 

Second :  The  impingement  of  terminal  nerve  fibres  supply- 
ing the  ovaries  occurs  when  ovaries  are  imbedded  in  inflamma- 
tory products.  These  inflammatory  products  are  cicatricial 
formations  and  like  other  scars  contract  with  increasing  grip 
as  the  months  and  years  go  by.  Atrophy  of  the  involved  ovary 
ensues,  but  so  long  as  its  terminal  nerve  fibres  are  not  com- 


448  ORIFIC1AL    SURGERY. 

pletely  destroyed,  their  incarceration  in  the  steadily  tighten- 
ing vice  of  cicatricial  tissue  is  a  prolific  source  of  sympathetic 
nerve  waste,  although  almost  universally  overlooked  and  ig- 
nored. Ovarian  tumors  in  themselves  are  not  seriously  detri- 
mental to  health,  but  cicatrix-entangled,  and  consequently 
pinched  ovaries  are  conditions  of  more  serious  import. 

Sympathetic  plexuses  supplying  the  fallopian  tube  may 
be  disturbed  in  their  functions  by  inflammatory  adhesions  be- 
tween the  fimbrias  at  the  other  extremity  of  the  tube.  It  is 
not  uncommon  to  encounter  tubes  that  have  been  entirely 
closed  at  their  outer  extremity  by  inflammatory  processes,  and 
impingement  of  terminal  nerve  fibres  of  the  sympathetic  en- 
sue as  a  consequence.  Congestion  and  inflammation  of  the  lin- 
ing of  the  tube,  and  also  pyosalpinx,  frequently  press  unduly 
upon  the  nervous  filaments  distributed  upon  the  surface  of 
the  membrane  lining  the  tube.  The  uterine  orifice  of  the  fal- 
lopian tube  may  become  excoriated  and  the  terminal  nerve 
fibres  distributed  to  this  point  may  be  unduly  squeezed  by 
prolonged  contraction  of  the  muscular  fibres  which  surround  it. 

Impingement  of  terminal  nerve  fibres  of  the  sympathetic 
supplying  the  lining  of  the  uterus  may  be  occasioned  by  clonic 
uterine  contractions  induced  by  corporeal  endometritis  and 
by  intrauterine  and  intramural  fibroids.  But  the  greatest  nerve 
center  of  the  uterus,  and  the  one  most  liable  to  injury,  is  the 
internal  os,  which  is  formed  by  circular  fibres  belonging  to 
the  body  of  the  uterus.  Flexions  of  the  uterus  have  their  bend 
at  this  point,  and  in  this  way  impinge  terminal  fibres,  and  this 
being  the  narrowest  point  of  the  uterine  cavity  it  suffers  most 
in  cases  of  endometritis,  and  is  apt  to  escape  the  attention  of 
the  gynecologist  because  of  its  concealed  position.  But  sten- 
osis, partial  or  complete,  of  the  internal  os  uetri  is  a  common 
source  of  sympathetic  nerve  waste  in  women  and  more  pro- 
lific of  mischief  than  is  credited  to  it. 

The  terminal  nerve  fibres  of  the  sympathetic  plexuses 
supplying  the  cervix  uteri  are  liable  to  suffer  impingement  in 
two  ways.  First,  by  stenosis,  and  second,  in  cases  of  prolap- 
sus uteri  by  impingement  against  the  perineum. 


OEIFIG1AL   SURGERY.  449 

Impingement  of  the  vaginal  nerves  occurs  most  frequent- 
ly at  the  two  extremities  of  the  vagina.  In  cases  of  vaginismus 
the  nerves  supplying  the  entire  length  of  the  vagina  are  in- 
volved. An  excoriating  leucorrhea  confined  to  the  upper  part 
of  the  vagina  is  a  frequent  occurrance.  The  mucous  mem- 
brane ultimately  becomes  denuded  of  its  epithelial  layer  and 
the  vaginal  sulcus  surrounding  the  cervix  in  the  course  of 
time  becomes  completely  obliterated  by  the  adhesions  of  the 
vagina  to  the  outer  surfaces  of  the  cervix.  The  cervix  no  lon- 
ger protrudes  into  the  vagina,  and  upon  examination  seems  to 
entirely  disappear.  The  adhesions  of  these  surfaces,  however, 
produce  unremitting  impingement  of  terminal  nerve  fibres,  and 
of  course  are  depleting  and  mischievous.  In  the  older  text- 
books it  is  common  to  meet  with  descriptions  of  uterine  condi- 
tions in  elderly  ladies  in  which  the  cervix  is  referred  to  as 
having  been  completely  absorbed.  The  large  majority  of  cases 
are  undoubtedly  those  in  which  the  upper  part  of  the  vagina 
has  first  become  excoriated  and  afterwards  adhered  to  the 
cervix,  so  that  while  the  cervix  in  reality  is  of  customary 
length  it  nevertheless  seems  to  have  disappeared  from  the  va- 
ginal canal.  This  condition  is  always  harmful,  and  yet  is  sel- 
dom deemed  worthy  of  mention  by  practical  gynecologists. 

Impingement  of  the  terminal  nerve  fibres  of  the  sympa- 
thetic at  the  lower  end  of  the  vagina  is  of  frequent  occurrence 
in  young  women  and  girls,  being  due  to  muscular  contractions 
at  the  os  vaginae  induced  by  irritable  conditions  of  the  hymen. 

Terminal  nerve  fibres  distributed  to  the  lining  of  the  blad- 
der are  seldom  disturbed  except  in  cases  of  calculi  or  of  cys- 
titis, and  when  tumors  press  upon  the  bladder. 

Terminal  nerve  fibres  of  the  sympathetic  supplying  the  mu- 
cous membrane  lining  the  female  urethra  seldom  suffer  im- 
pingement except  at  their  extremities.  Excoriations  of  the  os 
vesicae  serve  to  induce  it  at  the  upper  end  of  the  urethra  by 
reason  of  the  undue  tension  of  the  sphincter  vesicae.  Carun- 
culae  and  hypertrophied  papillary  and  glandular  growths 
about  the  orifice  of  the  urethra  frequently  occasion  terminal 
nerve  impingement  at  the  lower  opening  of  the  urethra. 


450  ORIFIC1AL    SURGERY. 

The  plexuses  of  sympathetic  nerve  fibres  supplying  the 
clitoris  and  its  hood  are  more  numerous  in  proportion  to  the 
size  of  the  organ  than  those  supplying  any  other  organ  in 
the  body.  Adhesion  of  the  hood  of  the  clitoris  to  the  clitoris 
induces  impingement  of  the  terminal  nerve  fibres  of  the  sym- 
pathetic supplying  this  part  because  the  clitoris  is  constructed 
of  erectile  tissue,  and  as  it  fluctuates  in  size  it  pulls  and  presses 
upon  the  adhesions  spasmodically  and  irregularly.  And  as 
such  adhesions  tend  to  undue  sensitiveness  and  excitability  of 
the  part  they  are  exceedingly  prone  to  seriously  disturb  a 
normal  sexual  rhythm  and  are  a  prolific  source  of  over-sen- 
sitiveness and  its  attendant  train  of  unhappy  consequences  in 
all  the  other  parts  of  the  female  sexual  apparatus  and  also  of 
the  rectum. 

The  terminal  nerve  fibres  of  the  rectum  suffer  impinge- 
ment in  either  hyperesthetic  or  anesthetic  conditions  of  its 
mucous  lining.  In  hyperesthetic  conditions  the  entire  mucous 
membrane  is  unduly  pinched  by  excessive  and  continuous 
squeezing  of  its  muscular  coat,  which  is  excited  to  over-activity 
as  a  result  of  the  nerves  supplying  the  mucous  lining,  and  in 
an  anesthetic  condition  of  these  nerves  their  terminals  are 
more  or  less  constantly  impinged  upon  by  the  presence  of  large 
masses  of  fecal  matter  which  the  insensibility  of  the  mucous 
lining  of  the  rectum  permits  to  be  retained.  Prolapsed  ovaries, 
fibroids  growing  from  the  posterior  surface  of  the  uterus  and 
pressure  from  the  fundus  of  the  uterus  itself  in  conditions  of 
retroflexion  and  retroversion  also  compress  the  sympathetic 
terminals  of  the  rectum  by  holding  the  walls  of  this  tube  in  too 
snug  a  coaptation. 

The  terminal  nerve  fibres  supplying  the  lowest  inch  of  the 
rectum  suffer  impingement  more  frequently  than  those  dis- 
tributed to  its  upper  part.  This  is  because,  first  it  is  the  most 
dependent  part  of  the  rectum ;  second,  it  is  the  narrowest,  most 
constricted  part :  third,  in  consequence  of  the  first  and  second 
reasons  it  is  the  part  most  prone  to  congestion,  to  laceration, 
to  excoriation,  to  bruises,  to  pathological  products  of  various 
kinds;  and  fourth  and  last,  because  the  circular  band  of  in- 
voluntary muscular  fibres  surrounding  this  part  are  more  nu- 


ORIFIG1AL   SURGERY.  451 

merous  and  more  powerful  than  in  any  other  part  of  the  reetum 
and  consequently  are  capable  of  a  severer  impingement  of  the 
sympathetic  terminals  distributed  to  the  mucous  membrane 
lining  it  when,  responsive  to  the  automatic  stimulus  of  the  sym- 
pathetic nerve  which  supplies  them  as  well  as  their  lining,  they 
are  held  in  clonic  spasm. 

Such  in  brief  are  the  various  ways  in  which  sympathetic 
nerve  force  can  be  wasted  or  disturbed  by  undue  impingement 
of  its  terminal  nerve  fibres. 

The  second  method  of  sympathetic  nerve  waste  or  dis- 
turbance is  by  excessive  and  unremitting  demands  upon  the 
sympathetic  nerve  supply  to  involuntary  muscles.  The  sym- 
pathetic nervous  system,  like  the  cerebro-spinal,  has  its  af- 
ferent and  efferent  nerves.  Its  afferent  nerves,  which  corre- 
spond to  the  sensory  fibres  of  the  cerebro-spinal  system,  are 
those  which  are  employed  for  surface  distribution,  and  these 
we  have  just  considered.  They  merely  convey  messages  from 
periphery  to  center.  The  efferent  nerves  of  the  sympathetic 
correspond  to  the  motor  nerves  of  the  cerebro-spinal,  and  are 
distributed  to  the  involuntary  muscles.  There  is  a  coat  of  in- 
voluntary muscular  fibres  surrounding  the  fallopian  tubes, 
the  uterus  is  constructed  of  involuntary  muscular  fibres,  the 
vagina  is  surrounded  by  a  coat  of  involuntary  muscular  fibres, 
the  bladder  and  urethra  are  similarly  provided,  the  blood  ves- 
sels and  lymphatics  are  wrapped  by  a  coat  of  involuntary 
muscular  fibres,  as  is  also  the  rectum.  It  costs  steam  to  run 
an  engine,  it  costs  electric  force  to  telephone  or  telegraph,  or 
to  heat  or  to  light,  and  it  taxes  nervous  centers  to  induce  mus- 
cular action. 

The  voluntary  muscles  are  supplied  by  the  cerebro-spina] 
system,  and  their  constant  activity  during  waking  hours  is  so 
exhausting  as  to  demand  that  a  third  of  our  time  shall  be 
spent  in  sleep  for  recuperative  purposes.  The  action  of  the  in- 
voluntary muscles,  however,  is  presided  over  not  by  the  ce- 
rebro-spinal, but  by  the  sympathetic  nerve.  And  so  essential 
to  our  existance  is  its  continuous  and  rhythmic  operation  that 
this  system  is  never  permitted  to  be  off  duty  from  the  begin- 
ning of  life  to  its  close.  For  legitimate  muscular  activity  on 

E  01-"   0£ 


452  ORIFIG1AL    SURGERY. 

the  part  of  the  involuntary  muscular  fibres  the  sympathetic 
nerve  force  is  ample  for  a  century  run.  But  if  in  response  to 
afferent  disturbance  the  efferent  or  draining  forces  are  un- 
duly taxed,  sympathetic  exhaustion  supervenes,  and  if  contin- 
ued is  followed  by  its  long  train  of  first  congestion,  then  dis- 
turbed function  and  imperfect  renewal  of  bodily  tissues,  then 
retarded  removal  of  debris,  and  finally  the  establishment  of 
every  possible  variety  of  pathology,  after  which  comes  prema- 
ture bodily  dissolution. 

The  operation  of  the  sympathetic  nerve  is  rhythmic  and 
automatic.  Activity  of  afferent  nerves  involves  activity  of 
efferent  nerves.  That  is,  a  disturbance  of  any  surface  supplied 
by  sympathetic  nerve  fibres  invariably  induces  muscular  ac- 
tivity of  the  involuntary  type  at  some  associated  part.  If  the 
irritation  be  transitory  in  its  nature  the  stimulated  muscular 
activity  will  be  likewise  transitory  in  its  operation.  But  if  it 
be  of  a  chronic  nature  the  muscular  activity  will  be  corre- 
spondingly prolonged.  In  this  way  does  terminal  nerve  irri- 
tation induce  sympathetic  exhaustion,  not  only  by  impinge- 
ment, but  also  by  unremitting  demands  upon  the  sympathetic 
nerve  supply  to  the  involved  muscles. 

The  third  way  in  which  sympathetic  nerve  force  is  wasted, 
as  mentioned,  is  by  impingement  or  undue  pressure  of  the  sym- 
pathetic nerve  trunks  themselves.  Such  impingement  may  be 
occasioned  by  misplaced  organs,  by  tumors,  or  by  deep  lacera- 
tions and  subsequent  cicatrical  formations  involving  nerve 
trunks  in  their  grasp.  Retroflexion  and  retroversion  of  the 
uterus  injure  not  only  the  terminal  nerve  fibres  of  the  sympa- 
thetic, which  are  distributed  to  the  lining  of  the  rectum  but 
also  the  large  bundles  of  plexuses  surrounding  the  rectum  it- 
self, and  lying  between  the  rectum  and  the  sacrum.  The  same 
is  true  when  enlarged  prolapsed  ovaries,  fibroid  growths,  ac- 
cumulations of  pus  or  serous  fluid  are  lodged  in  Douglas  cul- 
de-sac.  In  prolapsus  of  the  rectum,  in  cystocele,  in  rectocle, 
and  in  procidentia  the  sympathetic  exhaustion  which  ensues  is 
due  to  the  excessive  tension  upon  the  nerve  trunks  of  the  sym- 
pathetic. 


ORIFIG1AL   SURQEBY.  453 

In  these  various  ways  is  the  strength  of  the  gentler  sex 
unobtrusively,  because  unconsciously,  sapped.  The  sympa- 
thetic nerve  speaks  not  to  womankind  except  in  the  language 
of  function,  and  appeals  to  her  consciousness  only  as  disturbed 
functions  or  their  pathological  sequences  obtrude  themselves 
upon  the  attention  of  her  cerebro-spinal  organization.  But  if 
the  self-consciousness  of  a  woman  is  not  appealed  to,  her  vital 
force  can  be  spent  unobtrusively  until  death  ensues  as  a  conse- 
quence and  the  real  cause  of  her  premature  departure  may  com- 
pletely escape  detection.  So  much  for  the  sympathetic  nerve 
waste. 

The  repair  of  the  sympathetic  nerve  needs  but  little  atten- 
tion if  its  waste  be  stopped.  Local  feeding  of  accessible  parts 
governed  by  sympathetic  nerves,  electricity,  massage,  internal 
and  external  medication  are  all  of  remedial  value,  and  above 
all  are  regular  and  helpful  automatic  habits  essential  to  sym- 
pathetic vigor.  When  women  come  to  us  for  medical  advice 
they  have  become  aware  of  some  form  of  physical  or  mental 
derangement,  and  they  are  seeking  relief  from  some  conscious 
distress.  But  in  reality  every  trouble  which  they  suffer,  what- 
ever form  their  complaint  may  take  on,  has  its  real  beginning 
in  a  silent,  unconscious,  yet  nevertheless  actual  distress  and 
embarrassment  of  the  sympathetic  nerve.  "We  must  remem- 
ber that  the  sympathetic  nerve  force  controls  the  circulation, 
nutrition,  function  and  repair  of  each  and  all  of  the  organs 
of  the  female  pelvis,  and  these  have  no  other  reliable  and  con- 
tinuous source  of  nerve  supply.  When  its  rhythm  and  har- 
monious operations  are  undisturbed  by  undue  impingement  of 
its  terminals  or  plexuses,  or  by  exhaustion  from  exorbitant  de- 
mands made  by  undue  and  prolonged  tension  of  involuntary 
muscular  fibres,  there  is  sufficient  vitality  or  reactive  power  to 
ward  off  disease  and  maintain  health  in  any  and  all  of  the 
pelvic  organs.  But  to  embarrass  or  in  any  way  disarrange  the 
vital  power  which  denominates  the  pelvic  conditions  of  woman 
is  to  inaugurate  serious  pathological  transformations  which 
invariably  have  their  beginnings  in  disturbed  functions  and 
congestions,  and  in  due  time  passes  on  to  inflammations,  ab- 
scesses, tumors,  cancers,  and  every  other  possible  variety  of 


454  ORIFIG1AL   SURGERY. 

pathological  crystallization.  Thus  do  the  consuming  fires  of 
the  female  pelvis,  whose  ashes  take  on  different  shapes  and  are 
known  to  us  by  different  names,  and  which  have  been  so  ably 
considered,  have  their  incipiency  in  sympathetic  nerve  waste. 
Let  us  by  all  means  make  women  comfortable.  But  while  we 
remove  her  tumors,  evacuate  her  abscesses,  allay  her  inflamma- 
tions, and  correct  her  displacements,  let  us  at  the  same  time 
bear  in  mind  that  our  pelvic  work  to  be  effective,  complete,  per- 
manent, satisfactory,  rational,  must  also  include  all  possible 
considerations  relating  to  the  waste  and  repair  of  the  sympa- 
thetic nerve. 


CHAPTER  LIX. 


DILATATION  OF  THE  VULVA,  VAGINA  AND  UTERUS. 


E.   H.   PRATT,   M.   D. 


In  these  parts,  as  elsewhere,  dilatation  is  a  serviceable 
measure,  both  in  abnormal  conditions  of  contraction  and  in 
abnormal  conditions  of  relaxation.  In  other  words,  it  is  good 
for  hypergesthetic  and  also  for  anaesthetic  states ;  it  is  good  for 
spasmodic  conditions,  and  for  paralytic  ones.  Spasmodic  con- 
ditions of  the  vulva,  vagina  and  uterus  are  most  frequently 
met  with  in  unmarried  women  and  those  of  the  married  who 
have  never  borne  children.  Abnormal  relaxation  of  the  same 
organs  is  a  common  condition  in  sclerotic  and  tubercular  sub- 
jects, and  as  a  post-parturition  state. 

These  parts  of  the  female  sexual  apparatus  are  so  closelr 
associated  in  function  and  in  construction  that  conditions  of 
tension  or  relaxation  in  one  part  are  common  to  them  all.  Con- 
sequently they  must  be  treated  in  common,  and  they  will  con- 
valesce simultaneously.  Protracted  irritability  of  the  vulva, 
which  expresses  itself  in  a  spasmodic  action  of  the  sphincter 
muscle  guarding  this  opening,  frequently  is  furnished  with  a 
hymen  which  presents  upon  its  margin  numerous  papillary 
growths,  giving  the  margin  of  the  hymen  the  appearance  of 


ORIFIG1AL   SURGERY.  455 

a  fringe.  In  such  patients,  a  similar  condition  may  be  observed 
about  the  orifice  of  the  urethra,  and  in  examining  the  rectum 
I  have  usually  found  papillae;  if  not  papillae,  there  will  al- 
most invariably  be  encountered  a  marked  development  of  rectal 
pockets.  In  such  cases,  the  entire  hymen  is  to  be  trimmed 
away,  as  is  also  the  roughened  margin  of  the  urethra,  and  the 
vulva  and  urethra  thoroughly  dilated.  The  latter  can  be  nicely 
dilated  with  the  uterine  graded  sounds.  A  good  dilator  for 
the  vulva  or  the  vagina  is  the  rectal  bivalve  speculum. 

In  employing  the  instrument,  dilatation  should  be  prac- 
ticed intermittently  and  gradually,  so  as  to  secure  a  proper 
degree  of  dilatation  without  rupturing  the  perineum. 

Irritability  of  the  vagina,  if  sufficiently  protracted,  fre- 
quently develops  the  papillary  layer  of  the  mucous  membrane 
which  lines  this  tube,  transforming  it  from  the  smooth  velvety 
surface  which  it  should  present  to  a  rough,  fibrinous,  horny 
structure,  entirely  devoid  of  all  resemblance  to  a  mucous  mem- 
brane, and  inducing  vaginismus. 

Wherever  the  vagina  is  thus  roughened,  it  should  be  thor- 
oughly curetted,  and  its  undue  tension  overcome  by  means  of 
the  rectal  bivalve.  Here,  again,  care  must  be  exercised  not  to 
rupture  the  vaginal  walls,  as  such  an  accident  would  have  a 
tendency  to  aggravate  rather  than  to  relieve  the  vaginismus. 

Occasionally,  in  cases  of  uterine  catarrh,  where  the  dis- 
charge is  of  an  acrid  nature,  the  vagina  in  the  neighborhood 
of  the  internal  os  becomes  excoriated,  swollen,  and  finally 
strictured.  I  can  recall  several  cases  in  my  professional  ex- 
perience in  which  the  stricture  at  this  point  has  been  so  com- 
plete as  to  entirely  obscure  the  view  of  the  uterus,  and  give 
the  parts  the  appearance  upon  a  mere  casual  examination,  of  a 
case  devoid  of  a  uterus.  Bimanual  examination,  however, 
would  soon  dispel  this  illusion,  and  disclose  a  uterus  of  normal 
size  hidden  above  the  stricture.  In  such  cases  it  was  impossi- 
ble to  overcome  the  stricture  without  considerable  laceration 
of  the  vaginal  walls  which  required  subsequent  daily  packing 
of  antiseptic  wool  to  secure  a  restoration  to  a  normal  size. 

In  vaginismus,  it  is  often  necessary  to  repeat  thorough 
dilatation  under  an  anaesthetic  two  or  three  times  at  long  in- 


456  ORIFIC1AL   SURGERY. 

tervals,  or  to  insert  and  inflate  a  long,  rubber,  air  pessary,  to 
be  worn  at  the  discretion  of  the  physician. 

A  chronic  irritability  of  the  endometrium  is  also  product- 
ive of  irregular  growths  upon  its  surface.  These  growths  are 
usually  known  as  granulations.  Their  texture  is  prescribed 
by  that  of  the  uterus  itself.  When  that  organ  is  tough  and 
fibrinous  in  its  nature,  the  granulations  will  be  correspondingly 
firm,  and  are  removed  with  difficulty  even  with  a  sharp  curette. 
Where,  however,  the  uterus  is  soft  and  friable,  its  granulations 
will  be  correspondingly  tender ;  and  in  scraping  them  off  great 
care  must  be  exercised  not  to  curette  away  the  uterine  tissue. 


Either  condition  can  induce  uterine  stenosis,  which  may 
confine  itself  to  the  cervical  canal,  the  internal  os,  or  to  the 
entire  uterine  cavity.  The  latter  is  an  exceptional  condition, 
irritability  of  the  lining  of  the  uterus  being  usually  expressed 
by  a  spasmodic  state  of  its  gate-ways. 

Uterine  stenosis  may  be  accompanied  or  not  with  some  form 
of  flexion.  The  catarrhal  condition  which  occasions  it  may  be, 
as  catarrhal  affections  of  any  other  mucous  surface,  either  of 
the  atrophic,  dry  form,  or  of  the  hypertrophic  or  moist  type. 
The  same  treatment  is  applicable  to  both  forms  of  pathology. 

In  practicing  dilatation  of  the  uterus,  which  is  the  only 
satisfactory  remedy  in  such  cases,  the  first  treatment  should 
be  a  thorough  one  and  under  an  anaesthetic.  It  is  best  accom- 
plished by  means  of  the  graded  sounds,  which  the  following  il- 
lustrates. Sea-tangle,  sponge  and  other  uterine  tests  have  long 
since  been  abandoned  by  progressive  gynaecologists,  as  they  are 
prone  to  inaugurate  septic  conditions.  The  objection  to  valvu- 
lar dilators  is  their  tendency  to  bruise  or  tear.  In  this,  as  in 
all  other  surgical  procedures,  the  nearer  we  approach  the  pro- 
cess of  nature  the  more  satisfactory  are  the  results.  When  na- 
ture dilates  the  uterine  cavity  she  does  it  thoroughly  and  by 


OEIFIC1AL   SURGERY.  457 

a  round  body,  which  impinges  with  equal  force  around  the  en- 
tire circumference  of  her  gate-ways. 

In  employing  the  graded  sounds  for  uterine  dilatation, 
they  can  be  introduced  quite  rapidly  until  a  size  is  reached 
which  meets  with  considerable  resistance.  From  this  point  the 
succeeding  sizes  should  be  partially  entered  and  removed  al- 
ternately, so  that  the  tissues  are  stretched  intermittently  and 
gradually,  thus  avoiding  danger  of  laceration.  Successive  and 
increasing  sizes  should  be  passed  until  all  resistance  at  the  in- 
ternal os  is  so  completely  overcome  that  no  more  resistance  is 
felt  at  this  point  than  is  offered  along  the  rest  of  the  uterine 
canal,  the  sounds  always  being  carried  as  far  as  the  fundus. 

In  conditions  of  atrophy  of  the  uterus,  especially  in  women 
past  the  menopause,  great  care  must  be  exercised  to  avoid 
puncturing  the  fundus  of  the  organ.  This  has  happened  three 
times  in  my  personal  experience,  but  I  am  pleased  to  report 
that  in  none  of  the  cases  was  it  followed  by  unpleasant  conse- 
quences. Should  such  an  accident  happen,  all  subsequent  di- 
latation must  be  confined  entirely  to  the  cervical  canal  and  in- 
ternal os,  and  under  no  circumstances  must  any  liquid  be  in- 
jected into  the  uterine  cavity. 

After  dilatation  of  the  uterus  has  been  completed  to  a  sat- 
isfactory extent,  the  cavity  may  be  thoroughly  curetted, 
swabbed  out,  and  had  better  be  packed. 

There  are  three  favorite  locations  for  the  appearance  of 
granulations  in  the  uterine  cavity ;  one  just  above  the  internal 
os,  and  one  at  each  uterine  opening  of  the  Fallopian  tubes.  It 
is  not  uncommon,  however,  to  find  the  entire  uterine  cavity 
covered  with  granulations  requiring  the  curetting  of  the  en- 
tire surface.  The  curved  curette  is  serviceable  in  scraping  the 
horns  of  the  uterus,  while  the  straight  one  is  more  serviceable 
for  removing  the  granulations  at  the  fundus  on  the  anterior 
and  posterior  uterine  surfaces  and  about  the  upper  margin  of 
the  internal  os.  As  the  curette  acts  as  a  douche  as  well  as  a 
curette,  the  granulations  are  washed  out  of  the  uterine  cavity 
by  the  instrument,  so  that  the  completion  of  the  curetting  is 
signaled  by  the  disappearance  of  the  granulations  by  the  re- 


458  ORIFIC1AL    SURGERY. 

turning  stream.  While  curetting  it  is  well  to  hold  the  uterus 
firmly  in  position  by  either  the  single  or  double  tenaculum. 
[Better  use  guy  ropes. — Ed.] 

The  solution  employed  in  thus  douching  the  uterine  cavity 
may  vary  according  to  the  preference  of  the  operator.  Per- 
sonally, I  am  in  the  habit  of  employing  bichloride  of  mercury, 
1-4000.  I  have  never  seen  any  harm  come  from  the  injection 
of  this  fluid;  perhaps  because  I  am  very  careful  never  to  per- 
mit any  of  the  fluid  to  be  retained  in  the  uterine  cavity. 

As  soon  as  the  curetting  is  completed,  I  am  in  the  habit 
of  packing  the  uterus  with  antiseptically  prepared  candle- 
wicking.  The  candle-wicking  is  boiled  one  hour  in  bichloride 
solution,  1-2000,  and  then  for  an  hour  in  sterilized  water.  Af- 
ter this  it  is  kept  wrapped  in  sterilized  gauze  and  used  dry. 
For  packing  purposes,  the  uterine  dressing  forceps,  will 
be  found  satisfactory.  [Prepared  and  sold  under  the 
name  of  "Cordine." — Ed.]  The  candle-wicking  is  doubled, 
the  forceps  seize  the  wicking  at  this  point  and  carry 
it  to  the  fundus.  The  forceps  are  then  loosened, 
partially  removed,  and  made  to  seize  the  wicking  again,  and 
once  more  introduced  well  into  the  uterine  cavity.  This  pro- 
cess is  followed  until  the  entire  cavity  is  packed  snugly.  If 
there  be  any  oozing  resulting  from  the  curetting,  this  first 
packing  is  to  be  left  in  position  for  a  few  minutes  and  then 
removed,  and  another  packing  introduced.  This  process  is 
repeated  until  all  oozing  has  ceased  and  the  uterine  cavity  is 
thoroughly  dry.  The  wicking  can  then  be  severed,  a  piece  of 
silk  thread  fastened  to  its  outer  extremity,  which  is  pushed 
well  into  the  vagina.  If  the  uterus  be  an  irritable  one,  it  may 
be  well  to  leave  the  packing  in  position  for  a  few  hours  only. 
If,  however,  it  be  atrophied  and  indolent,  it  may  be  left  un- 
molested for  from  two  to  four  days,  according  to  the  amount 
of  reaction  desired.  After  the  removal  of  the  packing  it  is 
well  to  thoroughly  douche  the  vagina  with  sterilized  water  or 
boracic  acid  and  sterilized  water.  Only  in  exceptional  cases 
will  it  be  found  necessary  to  douche  the  uterine  cavity  itself, 
as  the  uterus  is  supposed  to  be  in  an  aseptic  condition  after 
the  completion  of  the  work,  and  the  manipulation  necessary 


ORIFIGTAL   SURGERY.  459 

to  introduce  a  uterine  douche  involves  more  or  less  trauma- 
tism  at  a  time  when  the  uterus  is  sensitive,  and  might  be  the 
means  of  setting  up  inflammatory  action. 

In  extreme  cases  of  stenosis,  especially  in  atrophied  con- 
ditions, even  dilating,  curetting  and  packing  are  not  sufficient 
to  restore  the  organ  to  a  normal  state;  but  it  will  be  neces- 
sary to  follow  this  first  operation  with  repeated  dilatations, 
which  may  be  done  without  an  anaesthetic,  at  intervals  ranging 
from  once  a  week  to  once  in  two  or  three  months,  according 
to  the  reaction  instituted.  The  secondary  dilatations  need  not 
be  carried  to  the  full  limit  of  the  first  one.  In  some  cases  it 
will  be  found  necessary  to  go  still  further  and  introduce  a 
uterine  stem,  to  be  worn  for  a  few  weeks  or  even  a  few  months, 
until  satisfactory  results  are  obtained. 

The  following  cuts  illustrate  the  forms  of  stem-pessary 
which  have  been  favorites  with  me,  either  of  which  I  can  rec- 
ommend in  such  cases. 


After  the  first  thorough  treatment  under  an  anaesthetic 
it  is  well  to  leave  the  uterus  unmolested,  except  as  it  may  be 
affected  by  vaginal  douches  or  tampons,  if  necessary,  so  long 
as  the  case  continues  to  improve.  But  if,  after  a  time,  im- 
provement ceases,  or  if  there  has  been  no  apparent  satisfac- 
tory reaction  from  the  work,  a  secondary  thorough  treatment 
under  an  anaesthetic  man  be  called  for. 

It  need  not  surprise  the  operator  in  employing  the  cur- 
ette at  this  second  sitting  to  bring  away  another  crop  of  gran- 
ulations. Whether  these  secondary  granulations  are  a  second 
growth,  or  merely  those  which  were  not  removed  at  first  treat- 
ment, is  difficult  to  decide,  but  nevertheless,  in  spite  of  the 
most  thorough  work,  it  will  oftentimes  be  found  necessary  to 
submit  a  uterus  to  several  curettings  before  the  uterine  gran- 
ulations can  be  effectually  and  completely  removed  or  ex- 
terminated. 


460  ORIFIG1AL   SURGERY. 

Catarrhal  conditions  are  difficult  to  exterminate  from  a 
mucous  surface.  Aurists  have  a  hard  struggle,  and  often  an 
unsuccessful  one,  with  catarrhal  conditions  of  the  middle  ear. 
Nasal  catarrh  is  likewise  usually  a  troublesome  affection.  Ca- 
tarrh of  the  sigmoid  and  rectum  is  frequently  overlooked,  and 
even  when  it  is  not,  yields  only  to  persistent  and  protracted 
after-treatment,  although  the  orificial  work  has  been  thor- 
oughly done  and  satisfactorily  finished.  Vaginal  catarrh,  and 
also  catarrh  of  the  bladder  are  equally  obstinate  affections, 
and  when  the  uterine  cavity  has  been  once  infected  by  this 
poison  it  is  no  less  obstinate  than  when  it  attacks  other  mu- 
cous membranes  of  the  body.  But  it  can  be  overcome  by  pa- 
tient and  persistent  effort. 

The  treatment  which  we  have  outlined  is  the  only  one  in 
which  we  have  ever  found  any  satisfaction  in  combating  this 
common  and  obstinate  affection. 

There  is  little  danger  when  practicing  uterine  dilata- 
tion in  over-doing  it  at  the  time  of  the  first  thorough  treat- 
ment or  operation,  if  sufficient  care  be  exercised  not  to  tear 
the  uterine  tissues.  But  there  is  danger  in  employing  subse- 
quent dilatations  too  frequently.  The  only  rule  which  we  are 
able  to  suggest  at  the  present  time  which  can  be  safely  fol- 
lowed in  all  cases,  is  the  rule  which  will  apply  equally  to  all 
sphincter-guarded  openings;  namely,  to  repeat  dilatations  un- 
til signs  of  reaction  begin  to  manifest  themselves.  The  points 
to  be  observed  in  deciding  this  question  are  the  color  of  the 
lower  extremity  of  the  mucous  membrane  as  it  appears  in  the 
field  of  the  speculum,  its  sensitiveness  as  it  is  demonstrated 
in  the  passing  of  sounds,  and  the  marked  increase  or  diminu- 
tion, as  the  case  may  be,  in  the  amount  of  the  vaginal  dis- 
charge. Examinations  may  be  made  at  regular  intervals  of 
longer  or  shorter  periods,  at  the  discretion  of  the  operator 
when  the  reaction,  which  has  been  instituted,  has  ceased.  If 
the  case  is  not  convalescent,  dilatation  by  hot  or  cold  sounds, 
intra-uterine  douches,  or  the  employment  of  a  stem-pessary 
may  be  resorted  to  to  stimulate  the  case  to  an  increased  ef- 
fort at  repair.  By  following  these  suggestions,  never  forget- 
ting that  cases  must  be  individualized,  hypertrophy  can  be  re- 


ORIFIG1AL   SUROERY.  461 

duced  and  atrophy  cured.  Dilatation  alone  is  not  a  panacea 
for  abnormal  degrees  of  tension  of  either  the  vulva,  urethra, 
vagina,  or  uterus;  but  it  is  a  necessary  part  of  all  successful 
treatment  of  the  diseases  to  which  these  parts  are  prone. 

Operative  procedures  will  next  claim  our  attention.  In 
the  great  majority  of  cases,  it  will  be  found  most  satisfactory 
to  do  thorough  all-round  orificial  work  at  the  time  of  the  first 
operation.  In  such  cases  it  is  well  to  do  what  work  is  neces- 
sary upon  the  sexual  organs  first,  reserving  attention  to  the 
rectum  as  the  last  part  of  the  work  to  be  done.  But  in  cases 
which,  in  the  estimation  of  the  surgeon,  are  too  delicate  to 
rally  properly  from  so  severe  a  nervous  shock  as  the  complete 
work  implies,  or  where  so  much  repair  is  needed  that  it  is 
injudicious  to  accomplish  it  all  at  a  single  sitting,  and  where, 
consequently,  a  choice  must  be  made  as  to  which  of  the  lower 
openings  of  the  body  had  better  be  attacked  first,  it  will  be 
found  advisable  to  operate  upon  the  rectum  first  and  reserve 
for  a  subsequent  sitting  the  repair  which  the  sexual  organs 
may  call  for. 


CHAPTER  LX. 


THE  CERVIX  UTERI. 


E.   H.   PRATT,   M.   D. 


Sometimes  it  is  too  long,  and  sometimes  too  short.  Some- 
times too  cone  shaped,  and  sometimes  too  club  shaped.  Some- 
times too  red,  and  sometimes  too  pale.  Sometimes  hypertro- 
phied,  and  sometimes  atrophied.  Sometimes  its  mouth  is  too 
large,  and  sometimes  too  small.  It  is  sometimes  in  a  hyper- 
aesthetic,  and  sometimes  in  an  anaesthetic  state.  In  other 
words,  it  shares  with  the  rest  of  the  body  all  the  possibilities 
of  pathological  variety. 

The  ideal  cervix  is  exceptional  in  the  cases  which  apply 
to  doctors  for  the  relief  of  chronic  suffering.  The  cervix  is 
so  distinct  an  organization  from  the  body  of  the  uterus  ner- 


462  OKIFIG1AL    SURGERY. 

vously,  as  to  almost  deserve  the  distinction  of  being  consid- 
ered a  separate  organ.  It  is  to  the  body  of  the  uterus  just 
about  what  the  basket  of  a  balloon  is  to  the  balloon  itself.  It 
is  a  very  highly  organized  structure,  and  its  condition  has 
much  to  do  with  the  health  and  happiness  of  its  possessor.  It 
prescribes  more  of  the  smiles  and  tears  of  a  woman's  life  than 
is  usually  appreciated.  It  colors  her  landscape  with  roseate 
hues,  or  darkens  it  with  clouds,  according  to  its  condition.  It 
not  only  influences  the  body  of  the  uterus,  and  through  this 
the  fallopian  tubes  and  ovaries,  but  its  telephone  wires  stretch 
out  and  beyond  to  every  nook  and  cranny  of  the  female  or- 
ganization. As  an  individual  structure  it  has  not  been  suf- 
ficiently studied.  If  its  mouth  has  been  too  small  it  has  been 
simply  incised.  If  it  were  too  large,  even  to  the  point  of  in- 
ducing extreme  ec.tropium  of  the  membrane  which  lines  its 
canal,  it  was  seldom  considered  important  to  reduce  it  to 
proper  dimensions  by  surgical  procedure,  except  as  it  could 
be  done  by  the  application  of  some  form  of  cautery.  The 
condition  of  the  terminal  nerve  fibers  at  its  extremity  as  a 
factor  in  health  and  disease  has  never  been  studied  to  any  pur- 
pose whatsoever  except  by  orificial  surgeons,  and  even  we  have 
not  completed  our  studies  in  this  direction.  How  often  do 
we  find  in  our  work  cases  which  appear  to  have  no  cervix 
whatsoever,  but  which  upon  examination  are  found  to  possess 
one  of  normal  length,  the  apparent  deficiency  being  caused 
by  adhesive  inflammation  between  the  upper  part  of  the  va- 
gina and  the  outer  surface  of  the  cervix,  to  such  an  extent 
that  the  sulcus  around  the  cervix  had  entirely  disappeared. 
What  a  state  of  irritability  and  distress  the  terminal  fibers  of 
these  surfaces  have  passed  through  to  have  caused  this  ad- 
hesive inflammation.  How  pinched  they  must  have  been  by 
the  contracting  cicatricial  tissue.  What  nerve  waste  must 
have  been  occasioned  by  this  long  and  tedious  process.  And 
yet  who  has  thought  of  its  importance  or  the  means  of  relief? 
So  frequently  in  examining  the  uteri  of  insane  girls  have  I 
found  the  entire  lower  end  of  the  cervix  denuded  of  its  epi- 
thelial layer  and  presenting  what  is  commonly  called  a  straw- 
berry erosion,  varying  in  size  from  a  dime  to  a  quarter  of  a 


OEIFIG1AL   SUEGEBY.  463 

dollar,  that  I  am  satisfied  that  it  is  by  far  the  more  common 
form  of  the  cervix  possessed  by  this  unfortunate  class  of 
cases.  This  is  the  condition  for  which  the  sovereign  remedy 
used  to  be  some  form  of  caustic,  nitrate  of  silver,  sulphate  of 
copper,  carbolic  acid,  the  actual  cautery,  or  some  other  vio- 
lently destructive  agent.  Repeated  treatments  of  this  severe 
nature  would  finally  produce  an  eschar,  which  would  destroy 
the  inflamed  appearance,  but  would  contract  upon  the  sensi- 
tive nerve  fibers  and  do  all  the  more  mischief.  So  that  while 
it  improved  the  appearance  of  the  end  of  the  cervix,  the  treat- 
ment almost  invariably  proved  detrimental  to  the  general 
health  of  the  patient.  More  of  hysteria,  undue  emotional  ten- 
dencies, irritability  and  irregularities  generally  of  the  female 
constitution,  are  due  to  morbid  conditions  of  the  end  of  the 
cervix  uteri  than  the  most  of  us  have  yet  dreamed.  Sometimes 
it  is  situated  high  in  the  pelvis,  and  its  irritable  nerve  fibers, 
gripped  unduly  by  the  spasmodic  condition  of  the  circular 
fibers  of  the  upper  part  of  the  vagina,  as  in  cases  of  vaginis- 
mus,  and  sometimes  the  sick  organ  is  prolapsed  sufficiently  to 
compel  the  sick  cervix  to  rest  upon  the  perineal  body,  chafing 
against  its  surface  not  only  with  every  step,  but  also  with 
every  sneeze,  every  cough,  every  burst  of  laughter,  every  sob, 
yes,  and  every  breath. 

As  to  treatment  for  morbid  conditions  of  the  cervix,  the 
same  principles  must  prevail  as  apply  to  the  orifice  of  the 
urethra,  the  orifice  of  the  vulva,  or  the  last  inch  of  the  rectum. 
Dilatation,  heat  and  cold,  local  applications,  either  soothing 
or  stimulating  according  to  circumstances,  and  electricity,  all 
have  their  use  and  should  be  given  a  fair  trial  where  patho- 
logical conditions  are  encountered.  But  when  their  effect  ap- 
pears to  be  merely  temporary  and  the  case  is  stubborn,  there 
is  a  sovereign  remedy  for  cervical  pathology  which  should 
never  be  forgotten,  namely,  amputation  of  the  cervix ;  not  of 
the  entire  cervix  so  much  as  the  removal  of  a  mere  slice  of  the 
lower  extremity,  so  as  to  dispense  with  the  diseased  terminal 
nerve  fibers  which  penetrate  its  surface. 

The  action  of  the  American  operation  is  no  more  mar- 
velous and  satisfactory  than  is  the  amputation  of  the  cervix 


464  OBIFIC1AL    SURGERY. 

in  cases  to  which  it  is  applicable.  It  is  not  a  serious  operation, 
is  apparently  harmless  in  every  respect,  and  is  so  frequently 
really  serviceable  that  when  its  importance  is  once  fully  re- 
alized by  the  profession,  there  is  some  slight  danger  that  it 
may  be  practiced  unnecessarily.  This  fear,  however,  must  not 
deter  us  from  its  proper  employment. 

Amputation  of  the  cervix  does  not  interfere  with  the 
ability  to  bear  children,  and,  if  it  should  be  done  a  few  times 
unnecessarily,  it  is  an  apparently  harmless  mistake.  It  would 
be  a  difficult  matter  to  lay  down  a  rule  which  would  be  a  sure 
guide  as  to  the  necessity  for  the  operation,  except,  perhaps,  the 
rule  which  it  has  been  found  well  to  follow  with  reference  to 
the  American  operation.  There  are  two  classes  of  cases  to 
which  it  would  be  applicable:  Severe  cases  of  hypertrophy, 
especially  when  accompanied  by  cystic  degeneration  and  ec- 
tropium,  with  erosion  and  pinching;  and  atrophied  conditions 
accompanying  deep-seated  reflex  conditions,  especially  abnor- 
mal mental  and  emotional  states  of  a  persistent  and  depress- 
ing nature.  Between  these  two  extremes  are  the  medium 
cases  of  moderate  degrees  of  pathology  and  the  simpler  form 
of  reflexes  that  can  be  relieved  by  the  higher  measures  of 
local  attention  to  the  part;  never  overlooking  the  fact  that 
needed  rectal  work  must  always  be  accomplished,  and  that  the 
clitoris,  urethra,  vulva,  and  sometimes  the  labia  minora  must 
be  restored  to  normal  conditions  before  satisfactory  results 
from  the  local  attention  to  the  cervix  can  be  secured. 

In  amputating  the  cervix  the  entire  uterus  should  first  be 
dilated,  curetted  and  packed.  Guy  ropes  should  then  be  in- 
serted in  the  very  tip  of  the  cervix  in  front  and  behind,  and 
tenacula  transfix  the  end  of  the  cervix  laterally  from  the  canal 
outward  and  be  held  apart  so  as  render  the  external  os  ob- 
long laterally.  A  pair  of  sharp-pointed  scissors  should  now 
be  employed  to  divide  the  mucous  membrane  around  the  cer- 
vix just  above  the  line  of  demarcation  between  the  healthy  and 
morbid  structures.  The  amputation  of  the  mucous  membrane 
should  be  carried  completely  around  the  cervix,  after  which  a 
pair  of  heavy  scissors,  their  blades  resting  in  the  line  of  the 
amputation  of  the  mucous  membrane,  can  be  closed  down  and 


ORIFIC1AL   SURGERY.  465 

made  to  amputate  the  cervix  evenly  and  to  the  extent  desired 
by  the  operator.  A  V-shaped  piece,  with  the  apex  pointing 
upward,  can  now  be  taken  from  the  cervical  lining  on  either 
side,  according  to  the  redundancy  and  flabbiness  of  the  tissue. 
Care  should  be  taken  to  make  the  ends  in  this  mucous  mem- 
brane very  straight  and  regular,  and  to  leave  the  strip  in  front 
and  behind  in  as  perfect  a  condition  as  possible  and  about  a 
quarter  of  an  inch  in  width.  A  silver  stitch  may  then  be  taken 
in  front  and  behind,  coapting  the  cervical  lining  with  the  sev- 
ered margins  of  the  vaginal  mucous  membrane.  Side  stitches 
can  then  be  inserted,  usually  two  on  each  side.  The  packing 
can  now  be  removed  and  the  operation  is  complete  so  far  as 
the  cervix  is  concerned.  But  of  course,  the  other  orifices  must 
be  examined  at  the  same  sitting,  leaving  the  rectum  to  the  last, 
as  the  handling  of  this  part  flushes  the  capillaries  and  re- 
lieves the  congestion  resulting  from  the  previous  work.  The 
stitches  may  be  removed  on  the  ninth  day,  as  in  case  of  lacera- 
tion of  the  cervix. 

There  is  no  more  satisfactory  operation  in  the  entire  cur- 
riculum of  orificial  surgery  than  amputation  of  the  cervix, 
when  the  ease  is  properly  selected  and  the  operation  is  well 
performed.  In  cases  which  have  a  tendency  to  retroflexion  or 
retroversion,  it  is  not  advisable  unless  a  radical  operation  for 
the  correction  of  these  conditions  be  performed  at  the  same 
sitting.  It  is  often  desirable  to  couple  this  operation  with  that 
for  laceration  of  the  cervix,  it  being  absolutely  essential  to  the 
health  of  the  woman  to  be  free  from  all  forms  of  cervical 
pathology. 

When  this,  with  the  other  forms  of  ordinary  orificial 
work,  fail  to  produce  a  satisfactory  result  in  the  treatment  of 
diseases  of  women,  it  will  be  in  those  cases  that  demand  hyste- 
rectomy and  oophorectomy. 


466  ORIFIC1AL    SURGERY. 


CHAPTER  LXI. 


IMPROVED  TECHNIQUE  IN  VAGINAL  HYSTERECTOMY. 


E.   H.   PRATT,   M.   D. 


First  of  all  the  patient  should  be  properly  prepared  for 
the  work.  If  the  tissues  of  the  vagina  are  in  fairly  good 
condition  this  may  be  accomplished  in  two  or  three  days,  but 
if  they  are  anemic  and  atrophied,  and  especially  if  they  show 
a  tendency  to  ecchymosis  under  manipulation,  fully  a  month 
should  be  devoted  to  local  feeding  previous  to  the  operation. 
This  can  be  accomplished  by  injections  twice  a  day  of  a  table- 
spoonful  of  bovinine,  holding  the  solution  in  the  vagina  by 
means  of  a  plug  of  cotton  inserted  in  the  vulva. 

The  immediate  preparation  of  the  patient  should  consist, 
as  in  other  cases  of  vaginal  hysterectomy,  in  a  thorough  evacu- 
ation of  the  bowels,  a  careful  scouring  and  shaving  of  the  vul- 
va, a  thorough  cleansing  of  the  vagina  with  soapsuds,  followed 
by  such  antiseptic  solutions  as  are  favored,  and  dilatation, 
curetting  and  packing  of  the  uterus  itself. 

In  some  delicate  cases  the  expansion  of  the  uterus  seems 
to  exercise  such  an  effect  upon  the  vitality  of  the  patient  that 
dilatation  must  be  dispensed  with,  and  so  of  course  also  the 
packing. 

The  preparations  having  been  completed,  two  guy  ropes 
are  inserted  into  the  lower  extremity  of  the  cervix,  one  an- 
terior and  the  other  posterior.  While  an  assistant  is  exposing 
the  cervix  by  the  aid  of  a  broad-bladed  Sims  speculum  pos- 
teriorly and  a  retractor  in  front,  the  operator  seizes  the  two 
guy  ropes  in  one  hand  and  with  the  other,  by  means  of  a  sharp- 
pointed  pair  of  scissors,  severs  the  mucous  membrane  of  the 
vagina  at  a  variable  distance  from  the  extremity  of  the  cervix. 
If  the  cervix  is  long  the  amputation  may  be  made  well  up,  but 
otherwise,  especially  in  those  cases  where  adhesive  inflamma- 
tion in  the  sulcus  about  the  cervix  have  resulted  in  adhesions 
between  the  mucous  membrane  which  covers  the  cervix  and 


OBIFIC1AL    SURGERY.  467 

that  which  covers  the  upper  part  of  the  vagina,  so  that  the 
cervix  itself  appears  to  be  excluded  from  the  vagina,  great 
care  must  be  taken  to  make  the  amputation  close  to  the  cervi- 
cal margin  especially  in  front,  in  order  to  avoid  wounding  the 
bladder,  which  in  such  cases  is  dragged  downward  and  will  be 
found  in  close  proximity  to  the  lower  end  of  the  anterior  lip 
of  the  cervix. 

In  thus  separating  the  walls  of  the  vagina,  if  the  end  of 
the  cervix  is  small  the  opening  can  be  increased  in  size  by  am- 
putating the  mucous  membrane  well  up  on  the  cervix  poster- 
iorly. As  soon  as  the  mucous  membrane  is  cut  through  the 
scissors  may  be  laid  aside,  unless  the  operator  prefers  to  con- 
tinue their  use,  and  the  spud  end  of  a  hysterectomy  knife  em- 
ployed to  peel  back  the  tissues  from  the  cervix. 

Beginning  this  dissection  in  front,  a  hole  is  made  through 
the  areolar  tissue  in  front  of  the  cervix  by  means  of  a  spud, 
perhaps  an  inch  in  depth.  The  spud  is  then  removed,  and  the 
instrument  is  reversed,  a  hysterectomy  knife  entering  the  hole 
made  by  the  spud,  and  the  tissues  carefully  separated  on  the 
other  side  of  the  hole  as  far  as  the  lateral  margins  of  the  cer- 
vix, care  being  taken  to  make  the  dissection  as  close  as  possi- 
ble to  the  cervical  tissues.  This  process  is  repeated  behind  the 
cervix,  after  which  a  double  tenaculum  is  employed  to  seize 
the  cervix  on  one  side  close  to  the  severed  margins  of  the 
mucous  membrane.  By  means  of  this  instrument  the  neck  of 
the  uterus  can  be  drawn  sideways  by  one  of  the  assistants, 
while  the  surgeon  by  means  of  the  hysterectomy  knife,  em- 
ployed under  the  guidance  of  a  thumb  and  finger  of  the  hand 
which  is  free,  dissects  away  the  tissues  from  the  side  of  the 
cervix  until  the  dissection  has  been  carried  to  a  level  with  that 
accomplished  anteriorly  and  posteriorly.  The  double  tenacu- 
lum is  then  removed,  and  made  to  perform  a  similar  service 
around  the  other  side,  and  the  process  of  dissection  employed 
also  upon  this  side  as  upon  the  other.  The  dissection  has  now 
been  made  evenly  around  the  cervix  as  far  as  the  neighborhood 
of  the  internal  os. 

The  operator  is  now  ready  to  enter  the  peritoneal  cavity. 
It  matters  little  whether  he  accomplishes  this  in  front  or  be- 


468  ORIFIC1AL    SURGERY. 

hind.  As  the  anterior  cul-de-sac  of  the  peritonium  where  it 
is  deflected  from  the  anterior  surface  of  the  bladder  is  per- 
haps easiest  of  access,  the  entrance  is  usually  made  in  front. 
To  accomplish  this  the  spud  is  employed  until  the  folded  mar- 
gin of  the  peritoneum  is  reached.  There  is  no  difficulty  in 
settling  this  point,  as  the  peritoneum  is  not  easily  detached 
from  its  attachment  to  the  anterior  surface  of  the  uterus.  By 
making  the  dissection  upward  while  the  operator  is  hugging 
the  anterior  surface  of  the  uterus  as  soon  as  the  instrument 
reaches  the  folded  margin  of  the  peritoneum  it  readily  slips 
beyond  the  fold,  which  is  then  brought  into  view.  If  the 
operator  is  not  satisfied  by  ocular  inspection,  by  inserting  his 
finger  in  the  hole  made  by  the  spud  he  can  readily  detect  that 
the  peritoneum  is  folded  upon  itself  in  the  upper  part  of  the 
wound,  and  by  employing  a  tenaculum  while  his  fingers  are 
still  inserted  in  the  upper  part  of  the  wound  he  can  seize  the 
rounded  margin  of  the  peritoneum,  draw  it  well  into  view, 
and  with  a  hysterectomy  knife  or  scissors  he  will  be  able  with- 
out difficulty  to  make  a  small  opening  into  the  peritoneal 
cavity.  With  a  T-forceps  he  now  seizes  the  severed  margin 
of  the  peritoneum  just  as  it  is  deflected  over  the  bladder,  and 
dragging  it  well  into  view  it  is  well  to  stitch  this  free  margin 
of  the  peritoneum  to  the  severed  margin  of  the  vagina,  plac- 
ing the  stitch  in  the  median  line  in  front  to  act  as  a  guy  rope. 
Although  this  stitch  is  a  temporary  one  it  is  serviceable  in 
keeping  the  wounded  surface  covered  and  in  placing  the  mar- 
gin of  the  peritoneum  always  at  the  command  of  the  operator. 
Passing  this  guy  rope  to  the  hands  of  an  assistant,  an  in- 
dex finger  of  the  operator  is  inserted  into  the  opening  and  the 
finger  flexed  to  one  side.  A  hysterectomy  knife  is  now  passed 
along  the  finger,  between  it  and  the  body  of  the  uterus,  and 
made  to  enlarge  the  opening  in  the  peritoneum,  first  in  one 
side  and  then  in  the  other,  as  far  as  the  sides  of  the  uterus. 
Great  care  must  be  taken  in  making  these  cuts  to  hug  the 
uterus  closely  in  the  dissection,  otherwise  the  point  of  the 
knife  will  wound  the  uterine  artery.  A  double  tenaculum  is 
now  embedded  in  the  posterior  surface  of  the  cervix,  and  while 
by  means  of  this  instrument  an  assistant  brings  the  field  well 


ORtPIClAL   SUROERY.  469 

into  view,  the  peritoneum  is  entered  posteriorly  in  the  same 
manner  as  was  accomplished  in  front. 

In  handling  the  tissues  back  of  the  cervix  it  will  be  fre- 
quently observed  that  the  breathing  of  the  patient  is  inter- 
fered with  and  the  anesthetic  should  be  suspended  for  the  time 
being. 

After  the  peritoneum  has  been  opened  in  front  and  be- 
hind, the  tenaculum  is  again  employed  laterally  and  the  dis- 
section of  the  broad  ligament  from  the  side  of  the  uterus  is 
made  first  on  one  side  and  then  on  the  other,  carrying  the  dis- 
section always  close  to  the  uterine  tissue.  The  guide  to  the 
closeness  of  the  dissection  may  either  be  made  by  the  free  hand 
of  the  operator  or  a  tenaculum  inserted  in  such  manner  as  to 
hold  the  tissues  tense  during  the  dissection. 

In  making  the  lateral  dissections  there  is  always  more  or 
less  danger  of  wounding  the  uterine  artery,  which  lies  embed- 
ded in  the  areolar  tissues  close  to  the  lateral  margins  of  the 
uterus.  If  through  careless  dissection  this  vessel  be  wounded 
it  should  be  immediately  seized  by  a  pair  of  artery  forceps 
and  secured  by  ligature,  or  simply  be  retained  in  the  grasp  of 
the  forceps,  to  be  secured  subsequently  by  the  continuous 
suture  which  closes  the  wound,  as  the  operator  may  elect.  In 
a  careful  dissection  the  artery  is  not  wounded,  and  conse- 
quently requires  no  ligature.  In  case  the  vessel  is  wounded 
and  the  surgeon  prefers  to  apply  a  ligature  immediately  this 
should  be  done  not  by  simply  tying  a  ligature  around  the  tis- 
sues as  they  are  grasped  by  forceps,  but  by  passing  a  thread 
beneath  the  artery  by  means  of  a  needle  and  then  tying  the 
knot.  With  this  precaution  there  is  no  danger  of  the  slip- 
ping of  the  ligature.  The  ligature  should  always  be  of  catgut. 

By  continuing  the  dissection  upward,  on  first  one  side 
and  then  the  other  in  the  manner  described,  the  uterus  can  be 
removed  without  wounding  either  the  uterine  artery  or  dis- 
turbing the  positions  of  the  ovaries  and  tubes,  the  fallopian 
tubes  and  the  ligaments  of  the  ovaries  being  severed  close  to 
the  body  of  the  uterus.  This  is  also  the  better  plan  to  be  pur- 
sued where  adhesive  inflammation  has  rendered  the  uterus 


470  ORIFIG1AL   SURGERY. 

fixed  in  its  position.  It  obviates  all  possibility  of  wounding 
either  rectum,  bladder,  uterus,  intestines,  or  omentum,  and 
accomplishes  satisfactorily  the  extirpation  of  the  organ. 

When  the  organ  is  movable  however  and  where  it  is  de- 
termined to  remove  the  tubes  and  ovaries  as  well,  as  soon  as 
the  openings  in  the  peritoneum  in  front  and  behind  are  accom- 
plished and  the  dissection  of  the  broad  ligaments  from  the 
uterus  is  made  and  the  dissection  carried  well  up  011  the  body 
of  the  uterus,  the  packing  is  removed  from  the  cavity  and  com- 
plete version  of  the  uterus  is  accomplished,  either  anteriorly 
or  posteriorly  as  the  operator  may  choose  or  the  case  demand. 

Where  there  have  been  adhesions  along  the  entire  body  of 
the  uterus  posteriorly,  binding  it  closely  to  the  rectum,  the 
index  finger  of  the  operator  can  be  carried  through  the  an- 
terior opening  in  the  peritoneal  cavity  and  by  crowding  it 
well  over  the  fundus  and  down  into  Douglas  cul-de-sac  these 
can  be  readily  broken  up. 

Under  ordinary  circumstances  the  organs  will  be  found 
easier  of  manipulation  if  the  version  is  made  through  the  an- 
terior opening  in  the  peritoneal  cavity  rather  than  the  pos- 
terior. To  accomplish  this,  while  the  guy  ropes  are  dragging 
the  uterus  well  down  a  double  tenaculum  may  be  inserted  into 
the  body  of  the  uterus.  Tension  upon  the  guy  ropes  is  now 
suspended  and  traction  made  upon  the  double  tenaculum.  As 
the  upper  part  of  the  body  of  the  uterus  is  brought  into  view 
it  is  seized  by  another  double  tenaculum,  traction  upon  which 
will  expose  still  more  of  its  upper  surface  into  which  another 
double  tenaculum  is  thrust.  Climbing  the  anterior  surface  of 
the  uterus  in  this  way  the  fundus  is  finally  reached  and 
dragged  down  to  the  peritoneal  opening.  On  either  side  of  it 
will  be  found  the  margins  of  the  broad  ligaments  containing 
the  fallopian  tubes,  and  if  the  ovaries  are  not  adherent,  these 
also  will  appear  in  the  field.  Sometime  when  the  mesentery  is 
very  long  it,  or  knots  of  the  small  intestine,  will  also  appear 
in  the  field. 

The  speculum  should  now  be  removed  and  the  double 
vulsellum  applied  to  the  fundus  of  the  uterus,  by  means  of 


ORIPIC1AL   SURGERY.  471 

which  one  of  the  assistants  can  hold  the  fundus  downward 
while  the  operator  proceeds  with  the  removal  of  the  tubes  and 
ovaries. 

If  the  intestines  or  omentum  obstruct  the  view  they  are 
to  be  held  back  by  a  tampon  inserted  into  the  opening,  to 
which  a  string  has  been  attached,  and  to  this  a  pair  of  artery 
forceps,  to  ensure  its  not  being  forgotten  before  the  wound  is 
closed. 

In  cases  where  the  tension  upon  the  tissues  is  great  and 
the  uterus  is  not  easily  dragged  downward,  it  is  well  to  split 
the  organ  in  an  antero-posterior  direction.  This  never  causes 
hemorrhage  of  consequence  as  the  uterus  is  not  a  bloody  organ, 
and  as  it  enlarges  the  field  of  operation  it  is  many  times  a  con- 
venient resort. 

When  the  ovaries  are  found  to  be  adherent  the  adhesions 
are  to  be  broken  up  by  the  index  finger  inserted  through  the 
wound.  It  is  sometimes  necessary  to  dig  them  out  of  a  mass 
of  inflamed  tissue,  but  their  removal  in  such  cases  is  all  the 
more  important  as  the  squeezing  of  the  ovaries  by  inflamma- 
tory products  is  in  itself  a  great  source  in  many  cases  of  de- 
pression of  the  vitality  of  the  patient. 

In  removing  the  ovaries  and  tubes  where  the  tissues  are 
sufficiently  lax  it  is  well  to  accomplish  this  from  above  down- 
ward, which  can  be  done  as  follows :  The  fimbriated  extremity 
of  the  fallopian  tube  is  seized  with  one  pair  of  T-forceps  and 
the  ovary  with  another;  both  forceps  are  then  placed  in  the 
palm  of  one  of  the  hands  of  the  operator,  while  the  index  fin- 
ger of  the  same  hand  is  passed  into  the  cul-de-sac  between 
them.  The  end  of  a  long  piece  of  No.  2  catgut  is  then  fastened 
into  the  folds  of  the  broad  ligament  beyond  the  point  where 
the  dissection  is  to  begin.  By  means  of  a  pair  of  blunt-pointed 
scissors  the  fallopian  tube  is  severed  from  its  attachment 
to  the  broad  ligament,  as  is  also  the  ovary  and  its  ligament. 
If  in  this  dissection  the  peritoneum  is  severed  close  to  the 
tube  and  the  ligament  no  hemorrhage  will  be  encountered. 
The  dissection  should  be  carried  as  far  as  the  lateral  margin 
of  the  uterus.  The  continuous  suture  already  started  should 
now  be  made  to  approximate  the  margins  of  the  wounded 


472  ORIFIG1AL    SURGERY. 

peritoneum  in  such  manner  that  the  two  wounded  surfaces 
are  turned  toward  each  other  and  nothing  but  a  narrow  seam 
along  the  free  margins  of  the  peritoneum  marks  the  situation 
once  occupied  by  the  fallopian  tube  and  the  ovary  and  liga- 
ment. The  other  side  is  to  be  treated  in  a  similar  manner,  af- 
ter which  the  broad  ligaments  on  either  side  are  to  be  severed 
with  a  pair  of  blunt-pointed  scissors,  care  being  taken  to  make 
the  dissection  close  to  the  side  of  the  uterus  so  as  to  avoid 
wounding  the  uterine  artery.  The  same  service  is  accom- 
plished upon  the  opposite  side,  when  the  specimen  will  be  in 
the  hands  of  the  operator  and  all  that  remains  to  be  accom- 
plished is  the  closure  of  the  wound. 

The  operator  now  has  at  his  command  the  two  long  cat- 
gut threads  already  mentioned.  By  means  of  one  of  these  the 
broad  ligaments  are  stitched  together,  thus  cutting  the  circu- 
lar opening  at  the  vault  of  the  vagina  into  two  smaller  circles. 
The  thread  employed  to  coapt  the  sides  of  the  broad  ligament 
may  now  be  carried  around  the  anterior  or  smaller  circle, 
while  the  remaining  thread  may  be  made  to  constrict  the  pos- 
terior or  larger  of  the  circular  openings. 

Of  course  if  any  sponges  have  been  inserted  into  the  ab- 
dominal cavity  they  should  be  removed  before  the  puckering 
strings  around  these  two  small  openings  are  drawn  together. 
It  is  also  well  before  closing  the  posterior  opening  to  give 
Douglas  cul-de-sac  a  thorough  sponging  in  order  to  remove 
all  blood  clots  that  may  have  accumulated  during  the  opera- 
tion. 

After  these  small  openings  have  been  closed  either  of  the 
threads  can  be  employed  to  close  the  wound  in  the  vagina.  In 
accomplishing  this  it  is  better  to  do  sub-mucous  work,  as 
there  is  no  tension  upon  the  wound  and  but  little  force  is  re- 
quired to  hold  the  parts  in  apposition.  The  seam  which  closes 
the  vagina  may  extend  in  either  an  antero-posterior  direction 
or  from  side  to  side,  as  the  operator  may  fancy.  When  the 
seam  is  half  way  completed  it  is  well  to  make  a  knot  of  the 
two  threads  employed  in  the  operation,  so  as  to  hold  the  broad 
ligament  in  close  coaptation  with  the  vault  of  the  vagina  to 
prevent  the  formation  of  hematoceles.  Either  thread  may  be 


ORIFIC1AL   SURGEKY.  473 

used  to  complete  the  closure  of  the  wound.  When  the  ex- 
tremity of  the  wound  is  arrived  at  the  thread  may  be  either 
tied  or  made  to  transfix  the  mucous  membrane  of  the  vagina 
half  an  inch  from  the  margin  of  the  wound,  and  its  extremity 
secured  by  the  application  of  one  or  two  perforated  shot. 

Throughout  the  operation  it  is  well  to  use  pitchers  of  hot 
water  freely  and  repeatedly,  to  clear  the  field  of  blood  clots 
for  purposes  of  cleanliness.  The  wound  is  then  dressed  ac- 
cording to  the  notions  of  the  surgeon,  either  with  or  without 
tampon,  with  or  without  medication,  as  he  may  elect. 

Most  cases  heal  by  first  intention  and  are  uneventful  re- 
coveries. Where  the  tissue  has  been  poor,  however,  its  bruis- 
ing may  involve  more  or  less  breaking  down  of  tissue  and  the 
subsequent  formation  of  a  small  abscess  in  the  areolar  tissue 
and  necessitate  the  reopening  of  the  wound  with  a  pair  of 
forceps  for  its  evacuation.  In  such  cases  the  wound  should 
be  dressed  daily  until  it  is  thoroughly  healed. 

The  ordinary  time  for  confinement  to  bed  is  two  weeks. 

In  cases  of  cancer,  where  the  cervix  has  been  destroyed 
and  the  upper  extremity  of  the  vagina  is  infected,  the  guy 
ropes  are  to  be  placed  half  an  inch  beyond  the  ulcerated  mar- 
gin and  the  dissection  carried  on  as  already  described. 

In  vaginal  hysterectomy  for  fibroids  in  most  cases  it  will 
be  necessary  to  split  the  uterus  in  an  anterior-posterior  direc- 
tion and  remove  the  fibroids  as  they  are  encountered. 

Large  sized  ovarian  tumors  can  also  be  removed  by  the 
vaginal  route  if  their  contents  be  first  evacuated  and  after- 
ward the  sac  dissected  away  after  the  manner  of  removal  of 
the  ovaries  of  smaller  size. 

I  am  thoroughly  persuaded  that  if  the  cases  are  carefully 
selected  and  the  operation  well  timed  and  performed,  and  the 
subsequent  treatment  skillfully  handled,  the  operation  should 
never  be  fatal.  The  operation  is  practically  devoid  of  risk 
to  life. 


474  OKIFIC1AL    SURGERY. 


CHAPTER  LXIi. 


VAGINAL  HYSTERECTOMY. 


FRANCIS    D.    HOLBROOK,    M.    D. 


The  point  has  been  settled  that  conditions  of  the  ovaries 
and  tubes  necessitating  removal  warrant  the  extirpation  of 
the  uterus  as  well.  If  the  removal  of  these  organs  is  neces- 
sary, choice  must  be  made  between  the  abdominal  or  vaginal 
route,  or  combination  of  the  two.  Notwithstanding  the  great 
progress  which  has  been  made  in  laparotomies  in  the  past  few 
years,  no  fair-minded  person  will  question  the  statement  that 
opening  the  abdomen  by  laparotomy  is  fraught  with  a  good 
deal  of  anxiety  to  the  conscientious  and  conservative  surgeon. 
Shock  is  more  pronounced,  drainage  not  so  good,  recoveries 
are  not  so  rapid  from  an  abdominal  hysterectomy  as  is  usual 
with  the  vaginal  method.  Where  it  is  possible  and  the  opera- 
tion is  advisable,  vaginal  hysterectomy  is  far  superior  in  the 
estimation  of  the  writer.  Tumors  of  the  uterus  or  appendages 
weighing  three  and  four  pounds  have  been  removed  by  way  of 
the  vagina,  showing  that  this  route  is  wide  in  its  possibilities. 

Deciding  then  for  the  vaginal  method,  we  have  four  rec- 
ognized procedures,  and  to  show  the  superiority  of  one  over 
the  others  is  the  aim  of  this  paper.  I  call  attention  to  the 
clamp,  the  ligature,  the  actual  cautery,  and  the  pratt  method. 
Dangers  arising  from  the  clamp,  the  ligature  and  the  cautery 
method  are  many,  some  of  which  are  impossible,  and  others  ex- 
ceedingly rare  by  the  Pratt  method.  I  have  had  the  pleasure 
of  assisting  the  originator  of  this  method  in  two  hundred  or 
more  hysterectomies,  and  have  performed,  personally,  the 
operation  without  a  death  in  forty-four  consecutive  instances. 

Some  of  the  dangers  following  total  extirpation  of  the 
uterus  are  as  follows:  Intestinal  obstruction  caused  by  the 
gut  adhering  to  margins  of  wound  or  being  included  in  the 
clamp  or  ligature.  These  conditions  have  not  been  recognized 
in  time  to  correct  and  have  proved  fatal.  Peritonitis  is  fre- 


ORIFIC1AL    SURGERY. 


475 


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476 


ORIFIG1AL    SURGERY. 


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ORIFIG1AL    SUR&ERY.  477 

quently  occasioned  by  the  bruising  and  pinching  of  the  tis- 
sues by  the  clamp  or  ligature.  Septic  conditions  are  not  un- 
common in  the  clamp,  ligature  and  cautery  methods,  as  large 
masses  of  tissues  are  crushed,  tied  or  burned  off,  injuring  the 
nutrition  of  the  parts.  Hemorrhage  is  occasioned  by  the 
clamp  or  ligature  slipping,  or  the  blood  vessels  retracting  into 


FIG.  C. 
Shows  uterus  anteflexed  with  fundus  brought  into  the  vagina. 

the  tissues,  or  from  sloughing.  If  for  no  other  reason  the  Pratt 
method  is  superior  in  that  large  masses  of  sensitive  sympa- 
thetic nerve  fibers  are  not  injured  or  destroyed,  which  means 
so  much  to  the  patient  and  to  those  who  appreciate  the  power 
of  this  system  and  who  study  its  waste  and  repair. 

After  thorough  preparatory  treatment  for  the  operation, 
the  patient  is  anesthetized.     Guy  ropes  are  placed  in  the  cer- 


478  ORIFICIAL    SURGERY. 

vix,  the  uterine  cavity  curetted  and  packed  with  sterilized 
gauze  or  candle-wicking  to  prevent  discharges  from  the  cavity 
and  to  give  body  and  compactness  to  the  organ.  An  incision 
is  made  through  the  vaginal  tissue  with  long,  curved-pointed 
scissors,  about  half  an  inch  from  the  external  os  in  front  (see 
dotted  line,  Fig.  I),  and  carried  behind  toward  cul-de-sac  in 


FIG.  4. 

Shows  fallopian  tubes  and  ovaries  after  removal  of   uterus.       T-forceps   on  upper 

portion  of  broad  ligament.      The  scissors  mark  point  where  tubes 

and  ovaries  are  dissected  off. 

a  V-shape,  to  give  a  larger  opening  than  the  circular  incision 
for  the  removal  of  the  organ.  Traction  is  then  made  on  the 
guy  ropes  and  with  the  scissors  the  vaginal  and  areolar  tis- 
sue is  dissected  off  the  cervix  (as  one  would  peel  an  orange), 
exercising  care  to  keep  close  to  the  uterus  as  the  bladder  is  in 
close  proximity  in  front  and  the  rectum  behind.  This  dissec- 
tion is  carried  to  a  distance  varying  from  one  to  two  inches 
from  the  original  incision.  The  peritoneum  is  now  encoun- 
tered and  is  opened  anteriorly  and  posteriorly.  The  lateral 
attachments  of  the  uterus  are  now  severed  to  a  point  as  high 


ORIFIGIAL    SURGERY. 


479 


as  the  origin  of  the  round  ligament  (see  Fig.  2).  With  a 
proper  degree  of  skill  the  broad  ligament  can  be  severed  with- 
out injury  to  the  main  trunk  of  the  uterine  artery.  In  the 
forty-four  cases  referred  to,  it  was  only  necessary  to  ligate  this 


FIG.  5. 

Fig.   5     Continuous  suture  of  catgut,  bringing:  together  cut  surfaces  of  peritoneum 
where  ovaries  and  tubes  were  removed. 

vessel  in  eight  instances.  At  this  stage  of  the  procedure  the 
uterine  packing  is  removed  and  the  cervix  closed  by  suture. 
The  fundus  is  then  brought  forward  through  the  opening  in 
the  peritoneum  into  the  vagina  in  an  extreme  anteflexed  po- 
sition by  a  large  tenaculum.  By  exercising  traction  on  the 
fundus  the  cornua  are  brought  into  view  and,  with  T-forceps 


480  ORIFIG1AL    SURGERY. 

applied  to  the  broad  ligament  to  keep  it  from  retracting,  the 
uterus  is  cut  loose  from  its  final  attachment  (see  dotted 
line,  Fig.  3). 

As  with  the  uterus,  so  with  the  ovaries  and  tubes  the 
main  blood  vessel  does  not  enter  the  organ,  but  lies  outside 
and  nourishes  by  smaller  vessels.  The  tubes  and  ovaries  are 


FIG.  6. 

Pig.   6.    The  broad  ligaments  being  sutured:  the  loop  in  the  centre  shows  how  the 
uterine  artery  can  be  included. 


dissected  off  with  scissors,  and  the  cut  margins  of  the  peri- 
toneum sewed  with  fine  catgut  (see  Fig.  5),  so  that  there  will 
be  no  raw  surface  in  the  abdominal  cavity.  The  broad  liga- 
ments are  now  coapted  longitudinally  with  No.  2  catgut  (see 
Fig.  6).  If  the  uterine  artery  has  been  injured  it  is  very  easy 
to  apply  artery  forceps,  as  it  is  plainly  in  view,  and  either 
ligate  it  independently  or  include  it  in  the  suture,  which 
brings  together  the  edges  of  the  ligament. 


ORIFIC1AL    SURGEEY. 


481 


The  next  step  in  suturing,  transversely  with  catgut,  the 
two  edges  of  the  peritoneum  which  was  severed  anteriorly  and 
posteriorly  to  the  uterus  on  entering  the  pelvic  cavity  (see 
Fig.  7).  The  cut  margins  of  the  vagina  are  now  sewed  with 
catgut,  except  at  the  lower  portion  of  the  wound,  in  which  a 
strip  of  iodoform  gauze  is  inserted  for  purposes  of  drainage, 
and  the  operation  is  completed. 


Fig.   7. 


Broad  ligaments  sutured  and  edges  of  peritoneum  being  sutured  which 
were  cut  on  entering  pelvic  cavity, 


The  time  of  accomplishment  of  this  operation  ranges  from 
thirty  to  forty-five  minutes,  and  except  for  the  removal  of  the 
iodoform  gauze  drainage  the  patient  makes  a  rapid  and  un- 
eventful recovery.  The  wound  will  have  thoroughly  and 
firmly  healed  in  two  weeks  and  the  patient  may  be  allowed  to 
get  up.  There  is  little  or  no  shock,  no  liability  to  hemorrhage, 
as  the  blood  vessels  are  in  view  constantly  and  can  be  tied  if 
occasion  demands  at  any  time  during  the  operation ;  no  lia- 


482  ORIFIdAL    SURGERY. 

bility  to  sepsis  or  peritonitis  from  other  causes  if  a  proper 
amount  of  care  is  exercised;  no  liability  to  hernia  of  intes- 
tines, as  the  ligaments  and  peritoneum  form  a  firm  floor  for 
the  pelvic  cavity ;  no  adhesions  to  intestines,  as  there  is  no  raw 


FIG.  8. 
Fig.  8.      The  peritoneum  sutured  and  pelvic  cavity  closed. 

surface  in  abdominal  cavity;  no  tying  of  sympathetic  nerve 
fibers.  With  the  broad  ligaments  brought  together,  the  sev- 
ered margins  of  the  peritoneum  united  and  the  vaginal  wound 
coapted,  the  merits  and  practicality  of  this  method  are  so  evi- 
dently superior  to  the  others  that  I  am  sure  it  will  win  its  own 
way  to  universal  recognition. 


CHAPTER  LXIII. 


CIRCUMCISION  OF  GIRLS. 


E.   H.   PRATT,   M.   D. 


The  condition  of  the  foreskin  of  boys  has  received  more  or 
less  attention,  at  least  since  the  days  of  Moses,  who  is  reported 
to  have  inaugurated  the  practice  of  circumcision  of  the  male 
portion  of  the  human  race.  But  the  girls  have  been  neglected. 
Without  presuming  to  pose  as  their  Moses,  I  do  feel  an  irre- 
sistible impulse  to  cry  out  against  the  shameful  neglect  of  the 
clitoris  and  its  hood,  because  of  the  vast  amount  of  sickness 
and  suffering,  which  could  be  saved  the  gentler  sex,  if  this 
important  subject  received  proper  attention  and  appreciation 
at  the  hands  of  the  medical  profession. 


OEIFIC1AL    SURGERY.  483 

All  up-to-date  doctors  realize  the  importance  of  the 
proper  condition  of  the  foreskin  in  the  male  and  of  securing 
it  during  infancy.  The  foreskin  must  be  completely  loosened, 
if  it  is  too  long  amputated  and  if  it  is  too  tight  slit  open,  in 
order  to  avoid  the  dangers  of  infantile  convulsions,  of  hip- 
joint  disease,  of  kidney  disease,  of  paralysis,  of  eczema  univer- 
salis,  of  stammering,  of  dyspepsia,  of  pulmonary  tuberculosis, 
of  constipation,  of  locomotor  ataxia,  of  rheumatism,  of  idiocy 
and  insanity,  and  of  lust  and  all  its  consequences.  But  the 
poor  girls,  who  have  an  organ  called  the  clitoris,  anatomically 
corresponding  to  the  penis  of  the  male,  with  a  hood  corre- 
sponding to  the  foreskin  of  the  male  and  just  as  sorely  in  need 
of  attention,  and  just  as  prolific  of  mischief  when  neglected 
as  the  corresponding  parts  of  the  male,  have  been  permitted 
to  suffer  on  in  silence.  The  same  list  of  diseases  which  have 
their  start  in  nerve  waste  caused  by  a  faulty  foreskin  in  the 
male  is  duplicated  by  the  female  sex  from  identically  the  same 
cause,  in  addition  to  other  troubles  peculiar  to  the  female  or- 
ganization from  which,  of  course,  the  males  are  exempt,  and 
yet  it  goes  on  almost  entirely  unrecognized.  Chorea,  so  fre- 
quent in  young  girls;  chlorosis,  which  comes  a  little  later  on, 
and  hysteria,  which  is  also  a  common  affliction,  in  addition  to 
the  same  diseases  from  which  boys  whose  foreskins  have  been 
neglected  are  liable  to  suffer,  have  their  origin  almost  invari- 
ably in  faulty  conditions  of  the  hood  of  the  clitoris.  It  is  such 
a  simple  matter  to  secure  a  normal  condition  of  the  hood  and 
its  clitoris,  and  its  neglect  is  fraught  with  so  much  and  such 
serious  mischief  to  the  gentler  sex,  that  the  sin  of  omission 
which  is  being  constantly  and  everywhere  committed  is  pain- 
ful to  contemplate.  Doctors  are  not  easily  educated  out  of 
their  beaten  tracks. 

For  instance.  A  little  girl  baby,  six  months  of  age,  was 
suffering  from  marasmus,  accompanied  by  thrush  and  cholera 
infantum.  The  little  thing  wasted  away  until  it  was  little 
more  than  a  living  skeleton.  Its  family  physician  had  done 
everything  in  his  power  to  stay  the  progress  of  the  disease, 
but  his  efforts  were  fruitless.  He  could  select  no  drug  that 
seemed  to  do  it  the  slightest  good,  and  what  food  was  pourod 


484  ORIPICIAL    SURGERY. 

into  the  child  was  rejected  so  promptly  that  the  poor  thing, 
all  efforts  to  the  contrary,  was  literally  starving  to  death. 
Aphthous  patches  completely  covered  its  mouth  and  fauces 
and  its  little  lips  were  dry  and  parched.  Finally  death  seemed 
very  near.  A  slight  convulsion  alarmed  the  parents,  and  the 
nearest  doctor  they  could  find  was  called  in  in  the  absence  of 
the  family  physician.  The  doctor  summoned  chanced  to  be 
familiar  with  the  principles  of  orificial  surgery,  and  not  know- 
ing what  else  to  do  made  a  local  examination  of  the  pudenda. 
To  his  surprise  he  found  the  hood  of  the  clitoris  very  much 
swollen  and  inflamed,  and  completely  adherent,  confining  con- 
siderable smegma.  The  margin  of  the  anus  was  also  excori- 
ated. 

Taking  the  probe  from  his  pocket-case  he  loosened  the 
hood  of  the  clitoris  from  its  attachments  and  cleared  away 
the  smegma.  No  blood  was  drawn  and  the  child  was  so  nearly 
gone  as  to  pay  little  heed  to  what  was  going  on.  After  loos- 
ening the  clitoris  the  doctor  inserted  the  little  fingers  of  both 
hands  into  the  anus  back  to  back,  and  gave  the  rectum  as 
much  dilatation  as  he  thought  the  case  would  bear  without 
rupturing  the  sphincter.  Without  changing  the  medicine,  but 
instructing  the  parents  to  simply  follow  the  directions  of  the 
family  physician  in  other  respects,  he  brought  his  visit  to  a 
close.  Remarkable  to  relate,  the  child  immediately  began  to 
change  for  the  better.  It  slept  peacefully  most  of  the  night, 
being  the  first  restful  sleep  it  had  known  for  many  weeks.  It 
began  at  once  to  retain  nourishment,  and  inside  of  forty-eight 
hours  all  semblance  of  thrush  was  gone,  and  its  little  digestive 
organs  were  performing  their  proper  functions.  The  mother 
had  been  instructed  to  dress  the  hood  of  the  clitoris  daily  so 
as  to  prevent  a  return  of  the  adhesions,  and  the  instructions 
were  carefully  followed  out.  A  rapid  recovery  followed,  and 
the  child  is  now,  some  years  hence,  the  hope  and  pride  of  the 
family. 

This  is  but  one  instance,  but  it  illustrates  innumerable 
others  in  which  sickness  and  death  have  baffled  the  doctors, 
and  where  a  little  timely  attention  to  the  hood  of  the  clitoris 
would  have  speedily  restored  the  entire  organism  to  harmony. 


OSIFIGIAL   SURGERY.  485 

Another  case  in  point  is  that  of  a  young  girl  about  eight 
or  ten  years  of  age,  who  had  injured  her  hip  and  a  few  months 
thereafter  presented  all  the  characteristic  symptoms  of  hip- 
joint  disease.  There  was  the  heat  and  tenderness,  swelling, 
slight  elongation  of  the  limb,  pain  in  the  knee,  soreness  of  the 
hip  joint  in  pressing  upon  the  knee,  and  also  in  pressing 
steadily  against  the  trochanter,  with  a  slight  tendency  to 
throw  the  knee  across  the  other  limb.  She  was  the  daughter 
of  an  eminent  physician,  and  the  poor  father  was  almost  crazed 
at  the  prospect  of  deformity  and  possible  death  which  was 
threatening  his  only  daughter.  The  case  was  presented  to  a 
doctor,  who  was  not  only  a  general  surgeon  but  an  orificialist. 
Recognizing  it  as  a  case  of  incipient  hip-joint  disease,  he  did 
not  neglect  to  make  an  examination  also  of  the  clitoris  and 
rectum.  He  found  in  the  rectum  a  few  small  pockets,  but  the 
rectum  otherwise  was  not  irritable.  The  clitoris,  however, 
was  in  a  very  irritable  condition,  and  its  hood  firmly  adher- 
ent. He  called  the  attention  of  the  father  of  the  child  to  the 
condition  of  the  parts  and  obtained  his  permission  to  anes- 
thetize the  child,  and,  without  giving  attention  to  the  hip- 
joint,  simply  loosened  the  hood  of  the  clitoris,  removed  the 
pockets,  and  dilated  the  rectum.  A  few  weeks  in  bed,  with- 
out even  employing  extension  upon  the  limb,  sufficed  to  re- 
lieve the  hip- joint  of  its  trouble  and  restore  the  limb  to  a  per- 
fectly normal  state.  A  few  months  later,  while  practicing  up- 
on roller-skates,  the  child  fell  upon  the  hip  which  had  but  re- 
cently recovered,  and  as  a  result  the  hip- joint  symptoms  again 
returned,  only  in  a  more  aggravated  form.  The  pain  in  the 
knee  was  greater,  the  swelling  and  redness  more  pronounced. 
The  father  this  time  summoned  another  surgeon,  to  obtain  the 
benefit  of  counsel  in  the  case. 

An  exploring  needle  was  run  into  the  thigh  in  the  region 
of  the  hip- joint,  and  the  liquid  which  was  drawn  into  th^ 
syringe  by  suction  was  pronounced  to  be  pus.  The  father 
then  took  the  child  to  the  first  surgeon  whom  he  had  con- 
sulted, with  the  request  that  this  time  the  hip-joint  be  laid 
apart,  and  whatever  general  surgery  the  hip  seemed  to  call 
for,  even  to  the  point  of  the  removal  of  the  head  of  the  bone 
and  the  curettement  of  the  socket  be  practiced. 


486  ORIFIG1AL   SURGERY. 

The  surgeon,  again  examining  the  hood  of  the  clitoris, 
found  that  it  had  been  permitted  to  reunite,  so  that  the  same 
causes  which  first  permitted  the  appearance  of  the  hip-joint 
trouble  were  still  in  active  operation.  But  as  he  had  prom- 
ised to  operate  upon  the  hip,  after  again  loosening  the  hood 
of  the  clitoris,  which  the  father  consented  to,  he  made  an  in- 
cision on  the  outer  side  of  the  thigh,  carrying  the  incision 
about  four  inches  in  length  over  the  trochanter  major,  and 
dissected  the  tissues  apart  until  the  capsular  ligament  of  the 
hip-joint  appeared  in  the  field  of  the  operation.  Although 
palpation  and  inspection  disclosed  no  bulging  of  the  liga- 
ment, an  exploring  needle  was  thrust  through  it,  but  no  pus 
was  extracted.  Not  satisfied  with  the  exploration,  the  spud 
of  a  narrow  scalpel  was  thrust  through  the  ligament  and  a 
small  quantity  of  the  joint  water,  which  appeared  perfectly 
normal,  was  evacuated.  This  satisfied  the  father  that  the  hip- 
joint  disease  of  the  child  was  in  its  first  stages,  or  that  of  con- 
gestion, and  that  the  consulting  surgeon  had  been  deceived 
as  to  the  nature  of  the  liquid  obtained  by  his  exploring  needle. 
Although  the  hip  was  red  and  hot  and  swollen,  although  there 
was  a  spasmodic  action  of  the  muscles  about  the  joint  im- 
pinging upon  the  nerves  so  as  to  produce  the  pain  in  the  knee, 
and  although  all  the  characteristics  of  hip- joint  disease  were 
present,  nevertheless  the  trouble  had  not  gone  on  to  suppura- 
tion, and  the  incision  into  the  hip  had  been,  therefore,  an  un- 
necessary procedure.  It  did  no  harm,  however,  as  it  healed 
by  first  intention.  The  child  was  an  exceedingly  nervous  one, 
and  it  was  a  difficult  matter  to  give  the  hood  of  the  clitoris 
the  daily  attention  which  it  needed  to  prevent  its  readhering. 
This  was  finally  accomplished,  however,  and  the  second  and 
permanent  recovery  of  the  case  was  finally  secured. 

Now,  in  neither  of  these  cases,  although  in  the  one  a  life 
was  saved  and  in  the  other  a  hip-joint  disease  checked  in  its 
incipiency  by  attention  to  the  terminal  nerve  fibres  of  the 
sympathetic,  as  they  are  found  in  the  pudenda  and  anus,  did 
the  physicians  seem  to  appreciate  that  the  loosening  of  the 
hood  of  the  clitoris  had  anything  to  do  with  the  recoveries 


ORIFICIAL    SURGERY.  487 

effected.  And  these  cases  are  mentioned  only  as  samples  of 
voluminous  history,  which  is  already  on  record  in  the  prac- 
tice of  orificialists. 

The  first  question  which  concerns  the  mother  after  the 
cry  of  her  new-born  infant  has  lighted  the  fires  of  maternal 
love  in  her  breast  is,  '"Is  the  child  perfect?"  The  doctor, 
knowing  this,  and  also  for  his  own  satisfaction,  from  a  pro- 
fessional standpoint,  carefully  examines  the  child  in  all  its 
parts,  with  a  view  of  determining  this  question,  so  all-im- 
portant to  the  family  concerned,  and  especially  to  the  child. 
A  tongue-tie,  a  cleft  palate,  a  spina  bifida,  an  imperforate 
anus,  supernumerary  toes  and  fingers,  birthmarks  of  all  kinds 
are  all  carefully  noted,  and  in  due  time  are  given  whatever  at- 
tention may  be  called  for.  But  in  spite  of  the  numerous  and 
wonderful  cures  that  have  been  effected  in  the  diseases  of  the 
gentler  sex,  both  young  and  old,  by  securing  a  normal  condi- 
tion of  the  clitoris  and  its  hood,  the  importance  of  taking  an 
invoice  of  this  part,  as  well  as  the  rest  of  the  baby,  at  the  time 
of  birth,  has  not  yet  received  even  a  shadow  of  appreciation 
which  is  justly  its  due. 

So  much  has  been  said  about  the  foreskin  of  boys,  and 
the  importance  of  securing  its  normal  state,  that  the  subject 
will  probably  pass  on  to  a  full  degree  of  appreciation  by  the 
entire  medical  profession  without  further  extensive  comment, 
as  almost  every  enlightened  physician  of  the  present  decade 
seems  to  be  more  or  less  fully  alive  to  the  importance  of  the 
subject.  But  the  application  of  the  same  thought  to  girl 
babies  will  have  to  be  harped  upon  and  discussed  and  pre- 
sented over  and  over  again  by  innumerable  writers  and  teach- 
ers before  the  girl  babies  are  privileged  to  enjoy  the  benefits 
of  free  terminal  nerve  fibres  in  the  region  of  the  clitoris.  The 
medical  journals  have  an  important  part  to  play  in  the  edu- 
cation of  the  doctors  upon  this  subject,  and  will  they  not,  for 
humanity's  sake,  give  the  matter  the  attention  which  it  has 
so  long  deserved,  but  failed  to  receive?  When  the  clitoris 
and  its  hood  are  in  a  normal  condition,  the  point  of  the  glans 
is  exposed,  the  complete  retraction  of  the  hood  is  easily  ac- 
complished, and  no  smegma  or  condition  of  irritability  is 


m  ORlFIGlAL   SURGERY. 

found  to  exist  between  them.  Upon  stretching  the  parts  lat- 
erally with  the  index  fingers  or  the  thumbs,  no  tension  of  the 
hood  is  discoverable.  Any  deviation  from  these  normal  stand- 
ards requires  attention.  If  the  hood  is  found  so  long  as  to 
completely  cover  the  glans,  it  requires  amputation;  not  com- 
pletely, for  in  that  case  a  cicatricial  band  would  form,  imping- 
ing the  clitoris  unduly,  and  leaving  the  patient  in  a  worse  con- 
dition than  before.  A  narrow  strip  of  mucous  membrane  and 
skin  must  be  left  intact,  so  that  complete  freedom  of  the  part 
can  be  secured.  If  the  hood  of  the  clitoris  is  adherent  to  the 
glans,  either  completely  or  in  part,  it  is  to  be  thoroughly 
loosened.  Whether  smegma  is  confined  or  not  matters  little 
in  all  such  cases.  After  the  tissues  have  been  separated,  they 
will  be  found  to  be  more  or  less  devoid  of  epithelium,  and  con- 
sequently will  be  red  and  irritable.  Hence,  the  necessity  of 
daily  retraction  of  the  hood  of  the  clitoris  until  this  epithelial 
layer  has  been  developed,  so  as  to  prevent  any  adhesions  tak- 
ing place.  If  the  hood  is  found  not  too  long,  but  too  tight,  it 
is  to  be  slit  along  the  dorsum,  and  a  stitch  of  fine  catgut  in- 
serted at  the  bottom  of  the  cut,  bringing  the  skin  and  mu- 
cous surfaces  together,  so  as  to  prevent  a  reunion  of  the  sev- 
ered edges.  Many  times  where  the  hood  of  the  clitoris  is  nor- 
mal, both  as  to  length  and  tension  and  adhesions,  the  parts 
are  probably  pale  and  anemic.  Measures  which  restore  tone  to 
tissues  in  other  parts  of  the  body  should  then  be  employed  to 
this  region,  as  a  healthy  condition  of  the  clitoris  and  its  hood 
is  absolutely  essential  to  a  vigorous  state  of  vitality  on  the 
part  of  its  possessor. 

The  importance  of  the  clitoris,  as  a  telephone  station,  in 
the  nervous  organization  of  women,  can  be  readily  observed 
by  the  use  of  a  single  stream  of  water  forcible  enough  to  con- 
stitute a  needle  bath  and  made  to  play  on  different  parts  at 
the  base  of  the  body  while  a  patient  is  under  an  anesthetic. 
When  the  patient  is  anesthetized  and  lying  in  the  dorsal  po- 
sition, while  an  assistant  is  holding  the  labia  minora  apart,  a 
fountain  syringe  being  elevated  as  much  as  possible  so  as  to 
give  the  stream  considerable  force,  by  means  of  a  small  glass 
tube  to  the  syringe  a  fine  and  forcible  stream  of  water  can  be 


ORIFIC1AL    SURGERY.  489 

secured  and  directed  against  the  anus.  In  most  cases,  a  slight 
tendency  to  contract  will  be  experienced,  although  many  times 
no  effect  whatever  will  be  produced.  Direct  the  stream  now 
against  the  perineum,  and  no  effect  whatever  will  be  noticed. 
Throw  it  against  the  labia  majora,  and  also  the  labia  minora ; 
these  parts  will  likewise  be  found  unresponsive,  as  will  also 
the  hymen.  If  the  stream  of  water  be  directed  against  the  ori- 
fice of  the  urethra,  a  spasmodic  condition  of  the  anus  will  be 
immediately  noticed,  and  also  in  many  cases  a  slight  contrac- 
tion of  the  clitoris.  This  effect,  however,  is  not  constant.  But 
now  direct  the  stream  of  water  against  the  end  of  the  clitoris, 
and  especially  up  under  the  hood,  and  almost  invariably  there 
will  be  a  convulsive  contraction  of  the  anus,  of  the  urethra, 
and  of  the  entire  body  of  the  patient.  Although  sufficiently 
anesthetized  for  ordinary  operative  purposes,  the  patient  will 
be  thrown  more  or  less  thoroughly  into  a  convulsive  state. 
If  the  stream  of  water  be  employed  in  the  same  manner  with- 
out an  anesthetic,  the  majority  of  women  will  not  complain  of 
the  jet  when  directed  against  the  anus  or  anywhere  about  the 
vulva,  except  in  two  places;  one  at  the  urethra,  and  this  not 
always,  but  when  the  stream  falls  upon  the  clitoris,  extreme 
nervousness  and  excitability  on  the  part  of  the  patient  are 
invariably  observed. 

Now,  when  one  realizes  that  all  the  involuntary  muscular 
fibres  of  the  body  upon  which  all  bodily  functions  and  activi- 
ties depend  are  sustained  in  their  operations  solely  by  the 
sympathetic  nerve;  and  when  it  becomes  equally  appreciated 
that  the  clitoris  and  its  hood  constitute  the  most  sensitive 
electrical  button,  which  can  be  pressed  to  arouse  this  entire 
sympathetic  nervous  system  to  increased  activity,  the  im- 
portance of  proper  treatment  of  this  delicate  and  influential 
anatomical  spot  will  be  more  thoroughly  established.  The 
pencil  of  nerves  which  supplies  the  sexual  organs,  although 
scattered  in  the  periphery,  unite  in  a  common  center,  wending 
their  way  to  the  solar  plexus  as  the  rays  of  light  climb  to 
the  sun. 

Impingement  of  any  one  of  the  terminal  nerve  fibers  of 
this  plexus,  by  affecting  the  condition  of  the  nerve  centers, 


490  ORIF1G1AL    SURGERY. 

can  thus  influence  any  and  all  the  parts  supplied  by  the  other 
fibers.  There  is  not  an  organ  in  the  body  that  contains  as  large 
and  numerous  a  sympathetic  nervous  connection  with  the  solar 
plexus,  in  proportion  to  its  size,  as  does  the  clitoris.  Why,  in 
the  name  of  all  that  is  reasonable  and  rational,  then,  should 
this  part  be  so  seriously  neglected?  It  is  as  important  to 
loosen  the  hood  of  the  clitoris  as  it  is  to  dilate  the  urethra,  to 
remove  caruncula?  from  the  urethra,  to  trim  up  a  roughened 
hymen,  and  to  secure  a  normal  condition  of  the  anus.  In- 
deed, if  one  were  to  choose  the  most  important  spot  in  point 
of  influence  over  the  entire  system,  it  would  have  to  be  the 
clitoris  and  its  hood.  The  state  of  sexuality  dominates  the 
bodily  vigor,  but  the  condition  of  the  sexual  organs,  as  a  whole, 
bears  no  more  important  relation  to  the  general  health  of  the 
body  than  does  the  condition  of  the  clitoris  and  its  hood  to 
the  health  and  tonicity  of  the  sexual  system  itself.  By  all 
means,  then,  let  the  girls  have  as  fair  a  start  in  life  as  the 
boys.  And  while  we  are  striving  to  check  the  tendencies  to 
sensuality  and  all  its  evil  consequences  in  the  male  sex,  let  us 
not  forget  the  importance  of  the  same  valuable  office  for  the 
female  sex.  It  is  an  all-important  measure  to  secure,  as  soon 
as  convenient  after  birth,  a  free  and  properly  proportioned 
foreskin.  It  is  an  equally  important  measure  to  give  equal 
and  early  attention  to  the  clitoris  and  its  hood.  Sensuality 
is  sufficiently  pitiable  and  mischievous  when  the  boys  are  neg- 
lected. But  the  neglect  of  the  girls  is  still  deeper  and  more 
disastrous,  if  possible,  in  its  consequences.  It  is  much  easier 
to  prevent  than  it  is  to  cure.  So  let  both  sexes  have  a  fair 
start  in  life,  and  be  entirely  freed  from  the  sexual  self-con- 
sciousness which  inevitably  comes  from  impinged  terminal 
nerve  fibres  about  the  clitoris  and  its  hood,  as  well  as  at  the 
glans  penis  and  its  foreskin. 


OEIFIG1AL    SUEGEEY.  491 


CHAPTER  LXIV. 


PERPETUAL   ADHESIONS  IN  LITTLE   GIRLS. 


ELIZABETH    H.    MUNCIE,    M.    D. 


This  subject  has  been  chosen  as  a  small  but  by  no  means 
insignificant  department  for  consideration  under  the  general 
subject  of  orificial  methods,  and  while  this  paper  is  to  treat 
only  of  preputial  adhesions  in  little  girls,  let  it  be  understood 
that  thorough,  all-round  orificial  work  is  urged  in  every  case 
presenting  any  degree  of  orificial  pathology  at  the  lower 
openings  of  the  body.  From  the  application  of  which,  in  many 
cases  there  has  been  no  cause  for  regret,  but  failures  have  been 
met,  before  courage  was  sufficient  to  remove  the  seemingly 
insignificant  pathological  lesion  as  well  as  the  greater.  In 
considering  this  much  neglected  subject,  it  may  be  profitable 
to  enter  into  a  detailed  description  of  the  structure  of  the  cli- 
toris, and  its  prepuce,  and  to  become  more  familiar  with  its 
nerve  supply.  Also  a  little  item  of  history  may  explain,  in 
part,  why  so  many  physicians  of  this  enlightened  day  are  still 
incredulous  as  to  the  advisability  of  giving  any  attention  to 
this  small  organ,  and  unhesitatingly  assure  themselves  and 
others  that  this  is  all  a  fad  and  soon  to  vanish  with  quack  nos- 
trums and  vain  imaginations  of  enthusiasts.  For  those  who 
fear  becoming  enthusiasts,  pity  is  reserved,  and  they  may  be 
comforted  by  the  assurance  that  there  is  no  danger  of  their 
catching  a  new  idea  early  enough  in  the  day  to  reach  such  a 
state  of  enjoyment.  So  long  as  they  prefer  to  look  wise  and 
denounce,  while  they  solemnly  declare  to  another  physician 
"in  the  same  boat"  that  they  are  not  altogether  sure  just 
what  the  normal  condition  is,  so  long  will  failure  be  met  on 
the  way,  which  otherwise  would  be  the  most  brilliant  success 
for  themselves  and  save  many  little  patients  from  countless 
ills. 

The  clitoris  is  the  analogue  of  the  penis,  consisting  of  the 
glans,  a  body  and  two  crura.  The  glans  is  the  only  part  vis- 


492  ORIFIG1AL    SURGERY. 

ible,  is  a  mass  of  erectile  tissue  about  the  size  of  a  small  pea, 
very  abundantly  supplied  with  nerves  and  partly  covered 
by  its  prepuce,  which  is  formed  by  the  junction  of  the  superior 
portion  of  the  labia  minora,  the  inferior  portion  uniting  to 
form  the  frenum. 

The  body  also  consists  of  erectile  tissue  about  an  inch 
long,  surrounded  by  a  firm  fibrous  covering  and  shown  on  sec- 
tion to  consist  of  two  halves  or  corpora  cavernosa,  separated 
by  an  imperfect  septum. 

Nerve  supply. — The  clitoris  receives  numerous  filaments 
both  from  the  sympathetic  system  and  from  the  pudic  nerve. 
It  will  here  be  noticed  that  the  nerve  supply  is  precisely  the 
same  as  that  to  the  glans  penis,  the  inferior  hypogastric  of  the 
sympathetic  and  the  pudic  of  the  cerebro-spinal.  "Small  as 
the  organ  is,  compared  with  the  penis,  it  has  (according  to 
Savage)  in  proportion  to  its  size,  four  or  five  times  the  nerve 
supply  of  the  latter." 

There  are  then  six  points  wherein  the  clitoris  is  an  ano- 
logue  of  the  penis :  First,  they  are  both  erectile ;  second,  they 
each  consist  of  a  glans,  a  body  and  two  crura ;  third,  they  each 
have  two  corpora  cavernosa,  separated  by  an  incomplete  sep- 
tum; fourth,  the  glans  in  each  is  partly  covered  by  a  prepuce 
with  a  frenum  attached  below;  fifth,  each  is  supplied  by  fila- 
ments from  pudic  nerve  and  hypogastric  plexus;  sixth,  each 
produces  a  cheesy  secretion,  smegma,  which  accumulates  and 
hardens  under  an  adherent  prepuce. 

Many  physicians  are  awakened  to  the  importance  of  cir- 
cumcision for  the  prevention  of  an  eczema  or  a  fatal  hydro- 
cephalus,  or  as  a  happy  deliverer  when  a  mother's  hope  might 
be  blighted  by  a  chorea,  epilepsy,  or  any  of  the  outgrowths 
from  masturbation.  Even  the  laity  are  concerned  in  regard 
to  the  infant  boy,  asking:  "Is  circumcision  needful?"  And 
just  here  a  plea  should  be  made  for  the  girls,  and  the  antici- 
pated results  that  will  follow  this  work  can  be  endorsed  by 
those  who  have  not  been  influenced  by  a  fancy  or  a  theory,  but 
from  personal  observations  which,  having  extended  over  sev- 
eral years,  have  clearly  demonstrated  the  importance  of  at- 


ORIFIC1AL    SURGERY.  493 

tending  to  perfectly  freeing  this  organ.  Results  in  many  cases 
have  been  immediate  and  astonishing,  in  others  not  so  marked. 

When  continual  pressure  and  irritation  of  this  most  sen- 
sitive organ  have  existed  from  infancy  to  puberty,  there  seems 
to  be  unmistakable  evidence,  though  often  disputed,  of  uterine 
and  ovarian  disturbance  originating  thereby,  for  an  adherent 
hood  may  produce  such  an  impression  upon  the  nerve  centres 
that  degeneration  of  the  entire  sexual  apparatus  of  the  unfor- 
tunate woman  may  follow.  For  instance,  clitoris  irritation 
will  lead  to  relaxation  of  uterine  ligaments  and  vaginal  walls, 
the  succeeding  malposition  of  the  uterus,  leading  to  disturb- 
ances of  circulation  which  in  turn  may  cause  degeneration  of 
the  ovaries  and  uterus.  The  symptoms  produced  from  the 
ovarian  or  uterine  complications  will  be  far  more  painful  than 
those  arising  from  the  actual  cause  of  her  ovarian  trouble. 
Removal  of  his  diseased  organs,  or  secondary  cause  will  not 
make  her  a  well  woman;  the  primary  cause  also  must  be 
reached. 

With  a  young  woman  suffering  from  any  disturbance  of 
the  sexual  system  an  adhesion  of  some  degree  is  usually  ex- 
isting. Even  though  it  be  only  slight  there  may  be  as  much 
pressure  from  imprisoned  smegma  as  though  the  adhesion 
were  greater.  As  with  a  boy,  the  principal  accumulation  of 
this  secretion  is  found  just  back  of  the  corona,  so  with  a  girl 
it  is  deeply  hidden  and  often  calcerous  in  its  consistency. 

That  in  adult  life  adherent  hood  is  not  found  as  fre- 
quently as  with  the  little  girl  may  be  explained  by  the  fact 
that  irritation  of  this  part  from  whatever  cause  attracts  at- 
tention to  that  part  and  leads  to  habits  which  sooner  or  later 
free  the  prepuce  from  its  attachment.  While  some  patients 
have  been  able  to  stand  this  condition  for  many  years  there 
are  countless  numbers  whose  resisting  powers  are  thereby  so 
lessened  that  they  sink  beneath  the  load. 

A  young  child  is  often  found  with  the  clitoris  entirely 
covered  by  its  hood,  and  the  vagina  completely  closed  by  a 
thin  film  or  membrane,  at  other  times  the  labia  minora  held 
together  by  filmy  bands  leaving  a  urethral  opening  only.  By 
this  means  the  girl  who  is  disagreeable,  irritable,  whining,  dis- 


494  ORIFIdAL    SURGERY. 

contented  and  spasmodic  in  every  motion  may  become  inter- 
esting, charming  and  possessed  of  every  childish  beauty.  When 
this  fact  is  generally  appreciated  by  the  profession,  there  will 
have  been  a  distinct  step  forward  for  the  blessing  of  humanity ; 
and  when  a  child  is  relieved  of  this  condition  an  estimate  can 
hardly  be  made  of  the  advantage  to  her,  not  only  for  this 
life,  but  perchance  for  eternity. 

Baker  Brown,  in  1867,  realizing  that  the  clitoris  played  a 
large  part  in  the  production  of  nervous  disturbances,  boldly 
removed  the  offending  organ  with  excellent  results  in  some 
cases,  while  in  others  great  disaster  followed  and  the  work 
fell  into  disrepute,  and  attention  to  the  clitoris,  so  far  as  the 
medical  fraternity  was  concerned,  into  oblivion.  Within  the 
last  few  years  this  much  neglected  organ  has  again  received 
consideration,  and  without  doubt  the  true  condition  is  now 
understood  and  the  proper  surgery  applied.  For  this,  as  well 
as  for  other  advances  in  surgery,  the  world  and  the  profes- 
sion owe  everlasting  gratitude  to  the  esteemed  and  noble  pi- 
oneer of  orificial  surgery. 

To  more  fully  emphasize  the  importance  of  the  subject 
under  consideration,  would  say:  Chronic  peripheral  irritation 
of  terminal  sympathetic  nerve  fibres  communicating  with  the 
centres  of  the  spinal  cord  and  brain  leads,  first  to  functional 
disturbance  of  any  part,  then  to  slow  structural  changes  in 
sympathizing  organs,  even  to  osseous  tissues,  and  finally  to 
deeper  complications  dependent  upon  the  functionally  dis- 
turbed or  degenerated  organs. 

Continued  irritation  of  terminal  nerve  filaments  leads  to 
function  disturbance  of  that  or  remote  parts  or  both ;  this  con- 
tinued functional  derangement  leads  sooner  or  later  to 
structural  change  which  means  organic  disease.  At  this  stage 
it  is  too  late  to  repair  the  damage  by  removing  the  first  causo. 
It  is  necessary  to  go  deeper  as  the  case  may  demand  anywhere 
from  the  simplest  operation  to  hysterectomy  or  laparotomy. 
It  is  our  duty  as  physicians  not  only  to  restore  the  lost  but 
to  prevent  the  destruction  and  save  our  girls  from  the  gradu- 
al invalidism  to  which  so  many  are  heirs  at  puberty  or  soon 
thereafter.  So  long  as  our  children  are  conceived  through  lust 


ORIFIC1AL    SURGEEY.  495 

and  seldom  from  pure  motives ;  so  long  as  our  young  men  re- 
main unrestrained  as  to  the  natural  and  legitimate  use  of  their 
sexual  organs  and  are  advised  by  physicians  to  marry,  con- 
suming their  passion  on  pure  and  noble  women  whom  their 
Creator  designed  they  should  cherish  and  love,  while  mothers 
are  too  modest  to  tell  their  children  of  temptations  they  will 
meet  and  fathers  are  indifferent  to  the  same,  just  so  long  will 
we  find  need  for  earnestness  in  every  effort  that  can  be  made 
to  save  body  and  soul. 


CHAPTER  LXV 


GYNAECOLOGICAL  REFLEXES. 


MOSES   T.    RUNNELLS,    M.    D. 


The  great  governing  center  of  female  life  is  resident  in 
the  pelvic  organs.  The  highly  wrought  and  sensitive  nervous 
system  of  woman  answers  quickly  to  peripheral  irritation,  and 
any  disturbance  of  the  sympathetic  terminal  nerves  of  the  pel- 
vis meets  with  corresponding  vibration,  and  is  often  greatly 
intensified  in  the  spinal  and  cerebral  centers.  We  are  per- 
plexed, oftentimes,  with  the  physiological  waves  affecting  the 
brain  as  the  result  of  great  epochs  in  the  functional  life  of 
woman's  reproductive  organs,  and  constantly  on  the  outlook, 
for  the  peripheal  nerve  pains  which  accompany  uterine,  over- 
ian,  or  rectal  disease.  Through  the  sympathetic  nervous  sys- 
tem, the  cerebro-spinal  center  may  be  slightly  or  profoundly 
affected  by  irritation  of  the  sexual  organs  or  rectum.  The 
ramifications  of  the  sympathetic  and  the  ganglionic  systems 
interwoven  with  the  filaments  of  the  spinal  nerves  are  so  com- 
plex that  it  is  often  very  difficult  to  locate  the  cause  of  reflex 
symptoms  but  it  is  a  notable  fact  that  female  genital  lesions 
find  expression  in  organs  remote  from  the  pelvis  and  these  re- 
flex phenomena  are  generally  the  most  striking  and  numerous. 

To  differentiate  between  physiological  and  pathological 
genito-reflex  neuroses,  nasal  and  anal  reflexes,  bronchial  neu- 


496  OKIFIC1AL    SURGERY. 

roses,  dermatoses  and  psychoses,  is  a  task  of  considerable  mag- 
nitude. The  uterus  and  ovaries,  the  vaso-motor  nerves  and  the 
central  nervous  system,  are  so  intimately  and  intricately  con- 
structed, that  the  circulatory  and  respiratory  systems  respond 
readily  to  morbid  impulse  conveyed  by  irritation  of  the  uter- 
ine, ovarian  and  anal  terminals,  and  pathological  changes  may 
follow  in  the  organs  of  circulation  and  respiration.  "The 
pneumogastric  nerve  is  a  bridge  which  unites  the  central  por- 
tion of  both  nervous  systems,  resembling  both,  not  well  iso- 
lated, often  anastomosing  with  the  sympathetic  which  helps  to 
form  the  coeliac  plexus  so  that  affections  of  the  vagus  and 
the  epigastric  ganglia  generally  coincide  and  the  visera  by 
their  ganglia  react  upon  the  brain,  and  a  paralysis  of  the  epi- 
gastric centers  causes  this  uneasy  sensation  in  the  pit  of  the 
stomach,  the  feeling  of  sickness  and  faintness,  nausea,  weak- 
ness, and  perverted  appetite."  (Tilt.) 

Leucorrhoea  and  uterine  pains  are  the  result  of  nervous 
debility,  and  hemorrhage,  or  a  cessation  of  the  menstrual  flow, 
may  give  rise  to  a  nervous  shock.  Epileptiform  attacks  are 
sometimes  due  to  stenosis  of  the  cervix  and  are  often  relieved 
by  dilatation  of  the  uterine  canal;  trachelorrhaphy  has  cured 
very  promptly  persistent  melancholia  with  great  nervous  de- 
bility; a  tampon  properly  applied  to  the  uterus  will  often  re- 
move the  burden  from  heart,  lung  or  brain. 

Laceration  of  the  cervix  frequently  causes  a  neurosis  or 
a  psychosis  which  may  not  disappear  until  many  months  after 
the  repair  of  the  cervix,  and  if  the  laceration  be  of  long  stand- 
ing, the  damage  to  the  nerves  may  never  be  overcome  and  the 
morbid  action  of  the  ganglia  implicated  will  not  subside.  Pain 
and  weakness  of  the  eyes  frequently  come  and  go  with  the  de- 
velopment and  cure  of  pelvic  inflammation.  Amblyopia  with 
complete  amurosis  has  occurred  as  a  well  marked  reflex  of 
uterine  disease.  Asthma,  dyspepsia,  headache  and  mental 
aberration,  one  or  more,  may  follow  derangement  of  the  fe- 
male sexual  organs. 

Uterine  and  ovarian  disease  is  often  accompanied  by  ner- 
vous irritability,  fear  of  impending  danger,  insanity,  insomnia, 
or  uncontrollable  desire  for  sleep  in  the  daytime.  Spinal  and 


OBIFIC1AL    SURGERY.  497 

hypogastric  pains,  with  pain  on  the  top  of  the  head  and  in  the 
hack  of  the  neck,  are  indicative  of  chronic  uterine  disturbance. 
These  facts  gleaned  from  clinical  experience  are,  more  or  less, 
familiar  to  the  gynecologist  whose  observation  has  taught  him 
that  the  heart,  stomach,  brain  and  pelvic  organs  of  women  are 
so  closely  related  to  each  other  that  a  lesion  in  the  pelvis  may 
(a"1  seriously  interfere  with  the  regular  action  of  the  heart  and 
give  rise  to  an  irregular  distribution  of  blood  in  various  parts 
of  the  body;  (b)  render  the  stomach  so  sensitive  that  the  use 
of  the  simplest  food  will  cause  uneasiness  and  great  pain ;  (c) 
retard  respiration  by  nervous  tension;  and  (d)  irritate  and 
hamper  the  whole  nervous  system  to  an  unlimited  extent.  A 
few  instances  of  hystero-psychosis  will  best  exemplify  the  im- 
portance of  the  foregoing  statements. 

Case  1. — Epilepsy  mitior  (petit  mal)  of  twenty-one  years' 
duration  cured  by  thorough  dilatation  of  the  uterine  canal. 
Miss  C.,  at  thirty-five,  was  always  delicate.  Menstruation  was 
established  at  fourteen  years  of  age,  at  which  time  she  began 
to  have  unconscious  attacks  coming  on  without  a  moment's 
notice,  except,  as  she  would  say,  "with  a  suffocating  feeling, 
then  all  would  be  blank  until  I  had  fully  recovered." 

These  attacks  would  last  from  ten  to  forty  minutes  and 
in  the  meantime  the  eyes  were  closed,  the  teeth  shut  closely 
together,  and  the  fingers  were  flexed,  more  especially  the 
thumb,  into  the  palm  of  the  hand;  the  breathing  was  ster- 
torous, the  muscles  rigid,  and  the  body  would  writhe  in  con- 
vulsions; the  limbs  were  violently  extended,  the  head  heavy, 
and  the  surface  cold;  she  would  often  cry  during  these  par- 
oxysms and  the  muscles  would  relax  and  she  would  lapse  into 
a  deep  sleep,  which  would  last  from  twelve  to  fifteen  hours 
when  she  would  awake  exhausted. 

The  attacks  were  ushered  in,  very  often,  by  the  close  at- 
mosphere of  a  crowded  room,  or  by  severe  cold,  or  by  the  ex- 
citement of  dancing,  running,  etc. ;  they  were  most  frequent 
during  the  menstrual  periods,  and  from  fourteen  to  twenty-one 
years  of  age;  one  summer  they  occurred  once  and  sometimes 
twice  a  day;  menstruation  was  usually  regular,  the  flow  quite 


498  ORIFIG1AL   SURGERY. 

excessive  from  five  to  seven  days,  but  much  of  it  came  in  clots 
with  great  pain  and  headache.  Under  the  influence  of  chloro- 
form, the  uterine  canal  was  dilated  about  one  and  one-half 
inches  which  produced  the  desired  effect.  The  menstrual  flow 
after  that  time  was  perfectly  normal  without  pain  or  head- 
ache. The  operation  was  performed  four  years  ago  and  there 
has  been  no  return  of  the  epilepsy  or  any  symptoms  of  it.  She 
was  married  at  the  age  of  thirty-seven  and  one  year  later  gave 
birth  to  a  healthy  girl. 

Case  2. — Melancholia  and  nervous  irritability  due  to  lac- 
eration of  the  crevix  and  areolar  hyperplasia  cured  by  the 
medicated  tampon  and  Emmet's  operation.  Mrs.  TL,  at,  thir- 
ty-seven, married  sixteen  years,  and  had  four  children, 
weighed  140  pounds  at  marriage  and  decreased  to  107  pounds ; 
was  always  regular  and  healthy  as  a  girl;  at  the  second  birth 
had  a  very  hard  labor  and  got  up  miserable ;  was  not  well  af- 
ter that  time;  gave  birth  to  the  third  child  in  1879  and  the 
fourth  child  in  1884;  "never  was  so  long  getting  strong  as 
after  the  birth  of  the  last  child;  was  four  months  before  she 
could  take  care  of  her  own  baby.  Despondency  and  irrita- 
bility began  in  1879,  was  discouraged  and  would  cry  easily: 
the  tendency  was  downward  continually  and  in  1887  found 
herself  drifting  into  insanity,  which  became  fully  established 
a  year  later. 

In  1888  the  case  was  placed  under  my  care  and,  on  ex- 
amination, I  found  the  neck  of  the  uterus  in  the  worst  stage 
of  areolar  hyperplasia,  and  lacerated  bilaterally ;  it  was  large, 
hard  and  sensitive ;  she  felt  as  if  a  heavy  stone  were  pressing 
down  on  the  top  of  her  head  and  she  could  not  think ;  was  con- 
scious that  she  was  losing  her  mind  and  was  anxious  to  ar- 
range affairs  for  the  family  before  going  to  the  hospital  for 
the  insane ;  was  always  thinking  that  she  was  going  to  have  a 
cancer  or  St.  Titus'  dance  or  some  other  horrible  affliction : 
stroking  the  forehead  would  immediately  cause  her  to  have  a 
nervous  paroxysm;  several  times  she  made  an  attempt  to  es- 
cape and  drown  herself  in  a  reservoir;  she  could  not  sleep  at 
night  owing  to  a  nervous  excitement ;  had  dreadful  dreams  and 
wanted  some  one  to  constantly  sit  with  her ;  was  constantly  in 


ORIFIG1AL    SURGERY.  499 

• 

dread  of  impending  danger;  had  an  aggravating  burning  sen- 
sation in  the  stomach  and  at  the  lower  end  of  the  spine;  it 
seemed  to  her  that  a  large  coal  of  fire  was  at  each  spot ;  music 
and  voices  were  heard  as  if  far  away;  for  two  months  previ- 
ous to  her  loss  of  mind,  had  a  heavy  weight  in  the  hypogas- 
tric  region  and  a  dragging  down  sensation  in  the  uterus ;  was 
obliged  to  move  slowly  and  sit  down  with  care,  supporting 
the  abdomen  to  prevent  pain.  The  condition  of  the  mind  im- 
proved, directly  the  areolar  hyperplasia  was  reduced  by  local 
treatment.  It  was  surprising  how  quickly  she  regained  with 
this  depletion,  and  the  melancholia  did  not  return;  the  lacer- 
ated cervix  was  repaired  and  in  three  months  the  woman  was 
restored  to  perfect  health  and  has  so  remained  for  four  years. 

CHAPTER  LXVI. 


AN  IMPROVED  METHOD  FOR  THE  REPAIR  OF  COM- 
PLETE LACERATION  OF  THE  PERINEUM. 


W.   E.   GREEN,   M.   D. 


The  pathological  changes  entailed  by  perineal  rupture  are 
multiple  in  character  and  gradual  in  development.  One  mor- 
bid condition  following  another  until  the  entire  pelvic  viscera 
is  involved,  all  of  the  organs  become  congested,  hypertrophied 
and  so  altered  in  their  positions  and  relations,  that  a  simple 
repair  of  the  perineal  body  alone  does  not  result  in  the  cure  of 
the  troubles,  the  restoration,  therefore,  of  the  pelvic  functions, 
after  severe  laceration  of  the  perineum,  requires  a  combination 
of  operations,  according  to  the  conditions  that  exist.  They 
may  be  executed  separately  or  they  may  all  be  done  at  the 
same  sitting,  as  circumstances  would  indicate. 

One  or  all  of  the  following  conditions  complicate  every 
case  of  complete  rupture,  viz. :  Laceration  and  hypertrophy  of 
the  cervix,  erosion  of  the  os,  endometritis,  subinvolution  and 
prolapsus  of  the  uterus  and  vagina,  relaxation  and  sagging  of 
the  anterior  vaginal  wall,  (cystocele),  thinning  and  stretching 


500  OBIFIG1AL    SURGERY. 

« 

of  the  recto-vaginal  septum,  separation  and  retraction  of  the 
torn  ends  of  the  sphincter  muscle,  and  atrophy  and  loss  of  con- 
tractile power  of  the  muscle,  hemorrhoids  and  sometimes  pro- 
lapsus of  the  gut.  In  order  to  obtain  satisfactory  results,  all 
of  these  conditions  must  be  considered  and  remedied.  It  has 
been  my  habit  to  divide  the  work  into  two  sittings,  doing  the 
operations  upon  the  womb  and  anterior  vaginal  wall  first,  leav- 
ing those  upon  the  perineum  and  rectum  for  a  subsequent  time, 
say  in  from  three  to  four  weeks  after  recovery  from  the  first 
operation.  The  patient  is  not  allowed  to  leave  her  bed  or  as- 
sume the  erect  position  until  all  the  work  is  complete. 

Strict  antiseptic  measures  are  observed  throughout.  The 
cervix  is  dilated  and  the  uterus  is  curetted  with  the  sharp 
curette.  If  a  laceration  exists  it  is  repaired,  or  if  it  is  an  elder- 
ly person  and  the  cervix  is  greatly  hypertropied  and  eroded, 
or  otherwise  badly  diseased,  it  is  amputated  by  a  modification 
of  Martin's  double  flap  operation,  removing  at  the  same  time 
all  the  indurated  and  scar  tissue  that  exists  along  the  line  of 
the  old  tear,  leaving  only  healthy  and  soft  structures.  (After 
recovery  from  this  operation,  if  well  done,  the  parts  present  a 
very  natural  appearance  and  involution  progresses  rapidly.) 
Anterior  colporrhaphy,  in  some  of  its  forms,  according  to  the 
demands  of  the  case,  is  then  done,  after  which  the  vagina  is 
irrigated,  dried,  dusted  with  iodoform  and  packed  with  anti- 
septic gauze.  This  packing  is  left  in  position  until  the  sixth 
or  seventh  day,  when  it  is  removed  and  the  parts  thoroughly 
and  regularly  douched  with  a  bichloride  solution.  The  stitch- 
es (catgut)  are  absorbed  by  the  eighth  or  tenth  day,  when,  if 
the  operation  has  been  aseptically  done,  and  cleanliness  has 
been  observed  in  the  care  of  the  case,  the  parts  will  be  found 
to  have  healed.  Suppuration  seldom  follows  and  union  almost 
universally  results.  Within  three  weeks  the  perineum  may  be 
repaired  and  the  finishing  touch  given  to  the  case. 

For  the  restoration  of  a  complete  laceration  of  the  perin- 
eum, I  have  devised  the  following  combination  of  the  flap,  or 
Streeter,  method  with  Pratt 's  operation  for  excision  of  the 
rectum.  I  have  done  the  operation  three  times,  with  perfect 
results  in  every  instance.  The  laceration  in  all  the  cases  was 


OBlFIGlAL    SUEGEBY.  501 

extensive.  The  perineal  body  was  completely  destroyed,  the 
sphincter  muscle  torn  entirely  in  two,  atrophied  and  contract- 
ed, leaving  only  a  thin  septum  between  the  rectum  and  va- 
gina, that  was  greatly  stretched  and  broadened.  The  troubles 
had  existed  for  twenty-eight,  sixteen  and  thirteen  years  re- 
spectively, and  all  had  incontinence  of  feces;  all  had  edome- 
tritis  and  subinvolution,  and  consequently,  in  all  the  cervix 
was  dilated  and  the  womb  curetted  with  the  sharp  curette. 
All  had  prolapses,  two  complete.  Two  had  bad  laceration  of 
the  cervix,  one  of  which  required  amputation,  the  other  trach- 
elorraphy.  Two  had  large  cystocele  that  demanded  anterior 
colporrhaphy.  One  had  pronounced  prolapsus  of  the  rectum, 
and  all  had  hemorrhoids,  that  could  only  be  relieved  by  ex- 
cision. In  one,  on  whom  the  cystocele  was  not  pronounced, 
the  work  was  done  at  one  sitting;  on  the  other  two,  at  two 
operations. 

The  operative  technique  is  as  follows:  First  rendering 
tense  the  recto-vaginal  septum  by  drawing  the  labia  aside,  an 
incision  is  carried  along  the  line  of  junction  of  the  rectal  and 
vaginal  structure,  and  then  upward,  on  either  side  to  the  high- 
est point  of  the  tear,  splitting  the  recto-vaginal  septum  and 
dividing  the  skin  from  the  vaginal  mucous  membrane,  after 
which,  the  flap  from  the  vaginal  mucous  membrane  is  dis- 
sected up  to  the  desired  extent.  The  first  step  of  the  Ameri- 
can, or  Pratt  operation,  is  then  done ;  viz. :  the  mucous  mem- 
brane of  the  gut  is  seized  on  a  line  with  the  upper  border  of 
the  internal  sphincter,  drawn  down  and  divided  all  round  by 
a  circular  incision,  dissected  down  and  removed  at  the  muco- 
cutaneous  junction.  The  ends  of  the  torn  sphincter  are  next 
secured  with  medium  size  catgut,  uniting  them  thoroughly; 
the  sphincter  severed  latterly  (as  recommended  by  Pratt),  to 
lengthen  and  weaken  it,  three  heavy  silk  approximating  liga- 
tures introduced,  as  in  an  ordinary  perineal  operation,  and  the 
deeper  portions  of  the  wound  brought  together  with  buried 
catgut.  The  silk  ligatures  are  then  tightened  and  tied,  and 
the  necessary  coapting  catgut  sutures  introduced.  The  flap 
is  treated  as  in  an  ordinary  permeal  operation.  The  gut  is 


502  ORIFIC1AL    SURGERY. 

then  grasped  with  the  forceps,  drawn  down  and  united  all 
round  to  the  skin,  completing  the  American  operation. 

This  is  the  most  perfect  and  promising  procedure  for  com- 
plete laceration  that  I  have  done.  The  vaginal  flap  protects 
the  wound  from  septic  contamination  from  above,  and  the 
healthy  gut  brought  down  secures  the  same  results  from  be- 
low, and  also  prevents  the  possibility  of  a  rectal  fistula,  be- 
sides giving  the  patient  a  "healthy  inch"  in  lieu  of  the  dis- 
eased condition  that  always  exists  in  such  subjects.  It  obvi- 
ates the  necessity  of  rectal  flaps  and  bringing  stitches  into  the 
gut  with  its  attendant  dangers  of  septic  infection.  When  union 
takes  place,  and  it  will  in  almost  every  case,  the  results  are  the 
most  perfect  that  could  be  desired. 

[See  chapter  on  "The  American  Operation."— Ed.] 


UilA<i'03Tfc.G    iG   H'rJH 


SECTION  VIII. 


Suggestive  Therapeutics 

as  an  aid  to 

Orificial  Surgery 


ORIFIC1AL   SURGERY.  505 


CHAPTER  LXVII. 


THE  PSYCHIC  FACTOR. 


E.   H.   PRATT,   M.   D. 


The  theme  chosen  for  consideration  is  one  of  interest  to 
us  all,  for  it  concerns  every  one  who  wants  and  watches  and 
waits.  And  what  soul  is  there,  clothed  with  flesh  and  dwelling 
among  us,  whose  cup  of  happiness  is  so  full,  whose  satisfaction 
is  so  complete  as  to  leave  nothing  to  be  longed  for,  nothing  to 
be  striven  after? 

The  activities  of  earthly  existence,  which  are  everywhere 
manifest,  are  pronounced  and  excessive.  Every  one  seems  in 
a  hurry  to  leave  somewhere,  or  to  get  somewhere,  to  escape 
from  something  or  to  secure  something,  according  as  they 
are  prodded  by  their  fears  or  enticed  by  their  hopes.  The 
chase  is  so  universal  and  so  precipitous  as  to  be  exhausting 
and  more  or  less  disastrous ;  hence  the  fatigue  and  the  distress 
which  seem  to  be  the  common  lot  of  us  all.  Some  of  us  have 
been  sick,  some  of  us  are  sick,  and  the  rest  of  us  will  be,  for 
in  this  respect  surely  history  will  repeat  itself.  All  the  run- 
ners who  have  started  in  the  race  of  life  except  one  has  stum- 
bled and  fallen,  and  that  one  was  crucified  through  the  envy 
of  his  fellows.  Alas,  how  true  the  soliloquy  of  Mark  Twain: 
"Be  good  and  you  will  be  lonesome." 

So  whatever  concerns  the  cause  of  our  happenings,  what- 
ever throws  light  upon  our  sickness  and  suffering,  whatever 
promises  a  more  comfortable  and  satisfactory  earthly  career 
is  a  matter  of  universal  interest.  The  surface  of  things,  which 
includes  all  objects  discernible  by  our  so-called  senses,  are  im- 
portant matters  for  consideration,  simply  because  it  is  only 
through  them  that  the  depths  of  existence  can  be  explored. 
Our  approach  to  the  spirit  of  things  is  invariably  by  way  of 
the  letter.  Erase  from  memory's  tablet  all  record  of  sense 
perception,  and  what  is  left?  Not  even  self-consciousness. 
What  we  have  seen,  heard,  smelled,  tasted  and  felt,  the  com- 


506  OBIFIC1AL    SURGERY. 

bined  facts  of  the  various  forms  of  our  physical  observation, 
furnish  the  basis  upon  which  all  philosophies  rest,  from  which 
all  our  reasonings  start,  and  are  the  premises  of  all  our  con- 
clusions. 

Nevertheless,  the  forms  of  things  are  not  the  things  them- 
selves; and  to  confine  our  studies  to  mere  appearances  as  we 
are  able  to  sense  them  is  to  seek  for  nourishment  in  husks.  In 
interpreting  all  writing  on  the  walls  of  time,  we  must  read  be- 
tween the  lines.  All  physical  facts  owe  their  existence  to  the 
operation  of  forces  which  no  eye  can  see,  no  ear  hear,  no 
tongue  taste,  no  nostrils  smell,  no  hand  lay  hold  of.  Elec- 
tricity, for  instance,  can  be  made  to  produce  light;  but  does 
anyone  mistake  the  light  for  the  power  itself?  It  can  be  shaped 
into  sound,  yet  the  whole  world  would  laugh  at  the  man  who 
claimed  to  have  heard  electricity.  This  same  force  can  be 
made  to  play  upon  matter  in  such  manner  as  to  appeal  to  the 
senses  of  touch,  taste  and  smell;  and  yet,  who  is  so  simple  as 
to  conceive  that  what  we  touch,  taste  and  smell  is  electricity 
itself  f  No,  the  real  power  is  not  discernible  by  physical 
means.  Yet  we  are  fully  persuaded  of  its  reality,  for  at  any 
time  we  can  appeal  to  it  according  to  the  laws  of  its  existence, 
with  which  we  are  now  more  or  less  thoroughly  acquainted, 
and  it  will  universally  assume  such  materializations  as  we  may 
demand  of  it.  The  world  believes  in  electricity,  although  that 
belief  is  based  solely  upon  mere  physical  manifestations,  which 
are  not  electricity,  but  simply  effects  which  electricity  can  pro- 
duce. 

What  is  true  of  electricity  is  equally  true  of  every  other 
force.  No  force  of  any  kind  is  ever  discernible  by  sense  per- 
ception. We  must,  therefore,  concede  that  the  same  is  true 
of  our  own  inherent  nature,  which  we  have  chosen  to  desig- 
nate as  the  psychic  factor.  The  soul  has  never  been  seen, 
heard,  smelled,  tasted  nor  felt  in  the  common  superficial 
meaning  of  these  terms,  but  its  accomplishments  obtrude  them- 
selves upon  our  attention  at  every  turn  and  tell  in  unmistak- 
able language,  to  all  those  who  are  willing  to  listen,  of  its 
existence. 


ORIFIGIAL    SURGERY.  507 

Enter  the  dissecting-room  in  all  honesty  of  purpose  to  ob- 
tain all  the  knowledge  possible  from  the  cadaver.  Lay  back 
the  skin  carefully,  dissect  away  the  areolar  tissue,  layer  by 
layer,  trace  out  the  course  of  every  artery,  vein,  nerve  and 
lymphatic,  make  careful  note  of  the  structure,  dimensions  and 
relations  of  every  organ,  even  to  the  bones  themselves,  and 
tell  me  whether,  with  all  your  fine  dissecting,  you  have  ever 
detected  even  a  trace  of  the  ghost  whose  earthly  habitation 
you  have  invaded.  Place  the  tissues  under  the  microscope, 
resolve  them  into  their  elements  in  the  chemical  laboratory, 
search  by  every  means  known  to  physical  science,  and  see  if 
even  then  you  can  catch  the  slightest  trace  of  that  mysterious 
power  which  animated  and  built  up  the  wonderful  piece  of 
mechanism  which  you  have  taken  to  pieces.  If  it  strikes  you 
as  a  singular  request  to  look  for  life  in  the  dead  body  you  can 
change  your  field  of  inquiry  from  the  dissecting  room  to  the 
operating  ampitheater,  and  while  the  lungs  are  respiring,  while 
the  pulses  are  throbbing,  while  all  the  wheels  o.t  life  are  in  mo- 
tion, make  dissections  and  analyses  to  your  heart's  content 
and  life  will  still  baffle  all  search  for  it  made  by  physical  meas- 
ures, so  you  can  see  it  is  just  as  well  to  perform  your  dis- 
sections and  tests  on  the  cadaver  as  you  will  find  every  phys- 
ical formation  as  completely  represented  in  the  dead  as  in  the 
living;  and  your  explorations  will  be  less  harmful  and  as  long 
as  you  are  sure  to  be  disappointed  in  your  search  it  matters 
little  where  it  is  made.  It  is  safe  to  assume  you  have  never 
found  life  by  any  process  of  physical  examination  or  explora- 
tion. If  you  have  never  found  life,  of  course,  you  have  never 
observed  health.  And  if  you  have  found  neither  life  nor 
health,  how  about  death  and  disease?  Even  a  moment's  seri- 
ous reflection  upon  these  subjects  should  be  sufficient  to  satisfy 
any  honest  truthseeker  that  the  greatest  study  of  mankind  is 
man,  and  that  until  medical  colleges  recognize  in  their  cur- 
ricula the  consideration  of  the  psychic  factor  in  both  health 
and  disease,  they  will  continue  to  perpetuate  a  race  of  mere 
body-patchers  instead  of  a  brotherhood  of  genuine  scientists, 
\vhose  equipment  in  the  healing  art  reaches  beyond  the  signs 
of  things  to  the  things  themselves. 


508  ORIFIG1AL    SUKGEBY. 

How  long  is  it  going  to  take  the  students  of  medicine  to 
realize  that  all  physical  facts  are  but  the  expression  of  in- 
dwelling forces,  and  that  the  surest  and  most  scientific  way 
to  change  results  which  are  unsatisfactory  is  to  deal  with  the 
underlying  causes  which  produce  them?  How  long  will  doc- 
tors adhere  to  a  mere  materialistic  conception  of  causation 
while  the  rest  of  the  world  is  worshiping  God?  In  most  medi- 
cal colleges  the  outer  man  receives  exclusive  consideration. 

Everybody  knows  that  the  status  of  painting,  of  music, 
of  literature,  of  architecture,  of  ornamentation,  of  inventions 
of  all  kinds,  of  husbandry,  and  of  all  the  accomplishments  of 
men  at  whatever  period  in  the  world's  history  they  may  be  ob- 
served, are  merely  the  evidences  of  the  condition  of  the  hearts 
and  heads  of  men  at  that  time.  And  everybody  knows,  if  they 
will  only  stop  to  think  about  it,  that  if  the  psychic  part  of  our 
natures  is  responsible  for  the  existence  of  our  observable 
selves,  our  physical  perfections  and  imperfections  alike  must 
have  their  origin  in  habits  of  the  soul.  So  that  while  with  our 
physical  measures  we  are  relieving  our  patients  of  the  results 
of  ill-ordered  lives,  we  by  no  means  institute  a  genuine  cure 
unless  we  succeed  in  directing  the  life  currents  of  the  patients 
out  of  disease-breeding  and  into  health-securing  channels.  We 
cannot  longer  dodge  this  great  issue  of  refuse  it  due  considera- 
tion, for  popular  sentiment,  bom  of  the  unsatisfactory  results 
of  the  practice  of  the  healing  art  conducted  on  a  purely  ma- 
terialistic basis,  as  it  has  been,  is  demanding  a  deeper  healing 
than  doctors  have  as  yet  accomplished.  They  are  no  longer  sat- 
isfied with  patchwork  and  palliatives.  They  are  loud  in  their 
demands  for  more  radical  results.  They  wish  not  merely  to 
be  relieved  of  suffering,  but  are  seeking  immunity  from  its  at- 
tacks. As  effects  can  only  permanently  disappear  when  their 
causes  have  been  removed,  they  are  demanding,  at  the  hands 
of  the  medical  profession,  such  a  knowledge  and  adjustment 
of  the  underlying  powers  of  life  as  shall  ensure  to  them  per- 
petual expressions  of  health  and  rid  them  forever  of  the  pest 
of  pathology.  The  people  themselves  have  come  to  realize 
not  only  the  existence  of  a  soul,  but  the  dominating  influence 
which  it  wields  over  all  bodily  conditions.  They  know  that 


ORIFIC1AL    SURGERY.  509 

happy  thoughts  and  feelings  conduce  to  a  good  appetite,  aid 
digestion  and  stimulate  the  blood  current,  upon  which  all 
functional  activities  of  the  body  depend.  They  know  that  un- 
happy thoughts  and  feelings  have  just  the  opposite  effects  and 
injure  the  appetite,  impair  digestion,  and  start  congestion  in 
various  parts  of  the  body.  They  know  that  disorderly  bodily 
functions  are  but  the  beginnings  of  severer  types  of  illness; 
and,  although  their  minds  are  unincumbered  by  high-sounding 
medical  terms  by  which  to  designate  the  various  types  of  ill- 
ness, and  although  they  are  ignorant  of  what  measures  doctors 
employ  to  effect  cures  of  them,  they  naturally  come  to  the  very 
common-sense  conclusion  that  the  way  to  avoid  effects,  and 
sometimes  to  cure  them,  in  matters  of  the  human  body  as  else- 
where, is  to  remove  causes  if  possible.  They  have  learned  that 
mental  states  and  conditions,  just  as  well  as  muscles  and  all 
the  physical  faculties,  are  capable  of  cultivation  and  develop- 
ment by  systematic  training,  and  they  believe  that  health  and 
happiness,  and  hope  and  trust,  and  love  and  virtue  of  all 
kinds  can  be  made  such  educational  accomplishments  of  the 
soul  as  to  insure  responsive  and  healthful  bodily  functions  of 
every  variety  and  bring  sickness  and  suffering  into  disrepute, 
and  stigmatize  their  victims  as  simply  the  willful  or  ignorant 
law-breakers  which  they  really  are. 

The  enlightened  part  of  our  community  today  knows 
more  of  the  evil  effects  of  fear,  of  anger,  of  jealousy,  of  hatred, 
of  sensuality,  and  of  all  other  forms  of  selfishness  upon  the 
physical  well-being  of  the  human  race  than  most  doctors  do, 
although  I  blush  to  make  the  confession.  Nay,  more  than 
this.  They  are  taking  the  matter  in  hand  and  propose  to  work 
out  their  own  bodily  as  well  as  spiritual  salvation  and  satis- 
faction right  along  this  line,  with  the  aid  of  doctors  if  they 
can  secure  it,  but  independent  of  them  if  the  medical  fra- 
ternity are  suicidal  enough  to  stand  aloof.  They  not  only 
know  the  disastrous  physical  consequences  of  bad  passions  and 
thoughts,  but  they  have  come  into  a  knowledge  of  the  remedy 
for  them.  As  light  scatters  darkness,  as  heat  displaces  cold,  as 
moisture  annihilates  drought,  as  sound  destroys  silence,  so 
they  have  found  that  trust  can  kill  fear,  love  kill  hate,  virtue 


510  OEIFIC1AL    SURGERY. 

kill  vice,  health  kill  disease,  and  life  hold  death  at  bay.  The 
people  themselves  know  all  this,  and  schools  of  right  living  are 
being  thickly  established  in  every  community  in  this  country. 
Music,  painting,  sculpture,  mechanics,  and  all  the  old-time  ar- 
tistic and  otherwise  serviceable  accomplishments,  are  not  in- 
terfered with,  but  there  is  added  to  them  a  school  of  the  soul, 
a  school  in  which  all  that  is  good  in  the  heads  and  hearts  of 
pupils  is  brought  out  and  developed,  and  all  that  is  bad  is 
discovered,  corrected,  and  weeded  out  by  systematic  train- 
ing according  to  the  best  known  scientific  methods  in  vogue  in 
other  departments  of  human  accomplishment.  This  new  school 
of  the  age  is  noi>  a  child  of  sickly  sentimentality  or  religious 
fanaticism,  but  is  thoroughly  scientific  and  practical,  and  the 
results  already  achieved  are  so  pronounced  that  its  students 
are  enthusiastic  in  its  praise.  The  God  worshipped  by  the 
new  school  is  spirit,  but  He  is  not  regarded  as  a  being  en- 
dowed with  ordinary  human  qualities  to  be  moved  by  prayers 
and  entreaties,  or  angered  by  abuse  or  neglect  on  the  part  of 
his  creatures,  but  is  simply  the  great  law-giver  whose  opera- 
tions among  men  are  carried  on  only  by  means  of  universally 
prevailing  principles  of  cause  and  effect,  as  mathematically 
exact  in  matters  of  mind  and  morals  as  in  physics ;  nay,  more 
than  this,  instituting  and  directing  all  physical  phenomena 
through  the  agency  of  indwelling  forces. 

The  stud}-  of  these  forces,  and  the  means  of  making  prac- 
tical application  of  them  in  all  the  affairs  of  everyday  life,  is 
the  work  which  they  have  laid  out  for  themselves.  They  be- 
lieve that  the  essentials  of  all  true  religions  are  identical.  But 
instead  of  being  matters  of  mere  tradition  or  sentimentality  or 
superstition  they  regard  them  as  nothing  more  or  less  than 
laws  of  spiritual  physiology,  a  life  according  to  which  secures 
health,  and  a  life  in  violation  of  which  invites  and  explains 
disease. 

Now,  while  everybody  admits  the  existence  of  thoughts 
and  emotions,  these  are  commonly  considered  very  vapory 
and  unsubstantial  entities,  and  but  few  people  as  yet  realize 
that  mind  .is  a  substantial  reality,  is,  indeed,  the  molten  sub- 
stance out  of  which  all  material  shapes  are  cast.  But  such 


ORIFIC1AL    SURGERY.  511 

is,  nevertheless,  the  case.  And  with  a  knowledge  of  this  great 
fact,  it  is  found  to  be  no  longer  necessary  to  leave  the  mis- 
chief of  the  world  brewing  at  its  fountain  head,  and  for  re- 
lief be  satisfied  with  mere  scurrying  about  in  a  vain  effort 
to  exterminate  the  consuming  fires  of  life  by  simply  clearing 
away  the  smoke  and  ashes. 

Mind  has  always  been  conscious  of  its  superiority  to  mat- 
ter; indeed,  has  held  the  entire  material  world  to  be  its  le- 
gitimate playground.  It  could  always,  through  its  material 
expression,  build  houses  and  tear  them  down  again.  It  could 
always  sing  songs,  write  books,  make  speeches,  wage  war, 
raise  crops,  breed  stock,  tame  forests,  direct  the  evolutions 
of  plant  and  animal  life,  transform  minerals  to  its  purposes, 
construct  factories  and  make  water  run  them,  could  paint 
and  carve,  could  touch  solids  as  with  magic  wand  and  turn 
them  into  liquids,  touch  liquids  and  transform  them  into  gases, 
confine  gases  and  convert  them  into  power,  harness  the  power 
and  command  it  for  all  forms  of  destructive  and  constructive 
purposes.  It  has  constructed  gigantic  microscopes  for  the 
more  careful  study  of  the  stars,  and  smaller  ones  with  which 
to  observe  the  infinitesimal  form  of  physical  creation. 

Nor  is  mind  yet  satisfied,  but  is  pushing  its  conquest 
still  further  in  hopes  of  enabling  men  to  fly  through  the  air 
like  birds  and  to  swim  under  the  water  like  fish,  and  is  am- 
bitious to  regulate  the  course  of  the  winds,  the  fall  of  the  rain, 
and  the  dashing  of  the  waves.  No  surface  of  land  or  water 
is  too  broad  to  be  traversed  and  to  be  strung  with  talking 
wires,  no  mountain  is  too  high,  no  depth  too  low  for  explora- 
tion. No  climate  is  too  hot;  none  too  cold  to  limit  investigation. 
Mind,  ever  active,  ever  expanding,  ever  inventive,  ever  irre- 
pressible, ever  aggressive,  ever  ambitious.  God-born  and  God- 
like mind  has  thus  come  down  into  time  and  space  and  turned 
the  whole  world  into  a  mere  workshop  for  the  kindergarten  ex- 
ercises necessary  to  its  own  evolution.  From  the  God  mind  has 
emanated  the  great  hidden  forces  through  whose  creative  ener- 
gies physical  existence  has  been  accomplished  and  continuous- 
ly sustained.  From  the  human  mind  has  come  the  energy  and 
intelligence  by  which  the  virgin  creations  of  the  God  mind 


512  ORIFIG1AL    SURGERY. 

have  been  reshaped  and  adapted  to  human  wants  and  neces- 
sities, the  results  being  harmonious  and  healthful  just  in  pro- 
portion as  man  has  been  able  and  willing  to  think  God's 
thoughts  after  Him,  and  discordant  and  disease-breeding,  and 
consequently  short-lived,  to  the  exact  extent  to  which  man 
has  ignorantly  or  willfully  differed  from  his  maker. 

God's  love  has  found  one  form  of  physical  expression  in 
heat.  Man's  ingenuity  enables  him  to  extract  this  heat  from 
numberless  sources  and  employ  it  to  his  liking.  By  its  use  he 
can  hatch  eggs  and  sprout  seeds,  can  cook,  dissolve,  melt  or 
burn,  and  consume  as  he  may  elect.  God's  truth  has  been 
crystallized  into  raindrops  so  abundantly  as  to  furnish  all 
creation  with  an  ample  supply  of  water  for  all  possible  pur- 
poses. Man's  intelligence  can  employ  it  for  purposes  of  con- 
struction or  destruction,  as  he  will.  It  is  the  same  with  all 
created  things.  The  whole  God-made  world  is  placed  at  man's 
disposal,  and  by  his  knowledge  of  its  laws  of  construction  and 
sustenance  he  can  build  up  or  tear  down  to  his  liking,  thus 
being  able  out  of  the  big  world  which  furnishes  him  the  crude 
material  to  secure  the  luxuries  and  necessities  with  which  to 
endow  a  private  habitation  suitable  for  his  occupancy.  As  the 
soul  of  God  has  clothed  itself  in  the  material  universe,  so  has 
the  soul  of  man,  which  is  itself,  like  the  rest  of  creation,  God- 
made,  taken  on  the  material  shape  which  constitutes  its  house 
of  matter,  in  the  health,  comfort  and  prosperity  of  which  we 
are  so  deeply  interested. 

No  attempt  will  be  made  to  present  an  argument  adapted 
to  the  annihilation  of  the  philosophy  which  holds  to  a  ma- 
terialistic causation  of  creation.  Those  who  look  upon  mind 
as  merely  the  result  of  brain  chemistry,  and  explain  in  all 
species  of  activity  upon  incomprehensible  conceptions  of  mo- 
lecular affinities,  are  at  perfect  liberty  to  stand  on  their  heads 
and  see  things  upside  down,  to  mistake  the  outside  for  the  in- 
side, the  effects  of  things  for  their  causes,  the  creatures  for 
the  creator,  to  their  hearts'  content.  It  is  useless  to  discuss 
light  with  the  blind.  It  is  taken  for  granted  that  most  of  us 
are  probably  already  persuaded  that  it  is  the  man  who  weaves 
the  garments  of  flesh  with  which  he  is  enveloped. 


OEIPIC1AL    SURGERY.  513 

The  burden  of  my  song  is  to  direct  your  attention  to  this 
great  fact,  and  to  the  resulting  fact  of  the  dominating  influ- 
ence which  the  soul  wields  in  all  forms  of  bodily  expression, 
be  it  those  of  health  or  disease.  As  students  of  medicine,  we 
are  ambitious  to  fit  ourselves  for  satisfactory  service  to  whom- 
soever may  be  our  patrons.  This  involves  our  ability  to  eradi- 
cate disease  and  establish  health.  We  must,  therefore,  neces- 
sarily be  interested  in  anything  that  will  render  us  valuable 
assistance  in  this  great  errand  of  mercy.  Now,  if  we  once  be- 
come fully  persuaded  that  the  mental  world  is  the  birthplace 
of  every  form  of  physical  expression,  and  if  we  further  learn 
that  the  conditions  of  this  same  world  are  subject  to  our  dic- 
tation, we  will  no  longer  confine  our  studies  to  the  surface  of 
things,  to  the  mere  appearances  which  are  discernible  by  sense 
perception  in  either  our  diagnoses  or  remedies,  but  gladly 
avail  ourselves  of  whatever  help  the  powers  of  mind  may  be 
able  to  furnish  us  in  the  prosecution  of  our  lifework.  Theo- 
retically, the  new  departure,  which  does  not  consist  in  the 
mere  recognition  of  the  spiritual  causation  of  things,  for  that 
philosophy  is  as  old  as  the  race,  but  in  the  recognition  of  the 
fact  that  thoughts  are  things  and  can  be  effectively  employed 
under  all  circumstances  to  transform  bodily  conditions,  may 
seem  sufficiently  plausible.  But  how  much  in  it  is  really  of 
practical  importance  in  the  healing  of  the  sick?  Can  mental 
states  in  reality  be  so  manipulated  as  to  shape  physical  condi- 
tions? If  so,  are  they  all-sufficient  for  remedial  purposes,  and 
is  our  present  equipment  of  hard-earned  medical  lore  an  un- 
necessary investment  and  incumbrance?  Or,  by  the  acquisi- 
tion of  mental  science,  will  we  simply  add  another  valuable 
remedy  to  our  list  of  remedial  agents,  which  appears  to  be  not 
yet  quite  long  enough  for  the  complete  subjugation  and  eradi- 
cation of  human  diseases? 

These  are  burning  questions  of  the  hour,  and  are  of  pro- 
found interest  not  only  to  the  laity,  but,  from  the  necessities 
of  the  situation,  to  doctors  as  well.  They  are  serious  ques- 
tions for  the  laity,  for  while  people  entertain  great  respect 
and  appreciation  for  the  indefatigable  labors  and  faithful  ser- 
vices of  the  medical  advisers  who  have  presided  at  their  birth, 


514  ORIFIC1AL    SURGERY. 

and  tended  them  in  sickness,  and  advised  them  in  matters  per- 
taining to  bodily  prosperity,  all  along  through  life's  journey, 
they  are  also  aware  of  the  limitations  of  professional  possi- 
bilities at  present  attained,  and  keenly  feel  the  need  of  more 
substantial  help  from  their  infirmities  than  doctors  have  as 
yet  been  able  to  furnish  them. 

The  natural  tendency  of  all  evolution  is  toward  higher 
forms  of  life,  and  especially  in  times  of  distress,  when  human 
help  proves  unavailing  and  mortal  doctors  fail,  man  instinc- 
tively searches  for  his  God.  It  is  the  fallibility  of  physical  help 
that  has  instituted  the  search  for  a  higher  means  of  relief  from 
which  more  effective  and  satisfactory  results  may  be  realized. 
From  this  search  has  come  the  discovery  of  the  mental  causa- 
tion of  both  "health  and  disease,  and  the  necessity  of  suggestive 
therapeutics  in  the  accomplishment  of  radical  cures  in  all 
cases  of  sickness.  The  laity  have  already  found  such  sub- 
stantial relief  that  their  sympathies  are  strongly  in  favor  of 
the  practice  of  mental  healing  wherever  it  may  prove  of  prac- 
tical service.  At  the  same  time  their  love  and  respect  for 
their  long-timed  and  faithful  servants,  the  doctors,  and  the 
consciousness  that  they  may  still  have  need  of  their  services 
in  such  cases  as  prove  intractable  to  mental  treatment,  makes 
them  hesitate  in  their  endorsement  of  the  new  form  of  treat- 
ment without  the  consent  and  endorsement  of  the  doctors 
themselves.  The  doctors  are  deeply  concerned,  for  if  there  is 
anything  of  practical  service  to  humanity  in  the  employment  of 
psychic  forces  in  the  cure  of  disease,  they  will  be  only  too 
glad  to  avail  themselves  of  its  helpfulness.  The  only  question 
with  them  is  one  of  utility.  They  are  loath  to  give  their  en- 
dorsement to  any  system  of  healing  until  its  virtues  have  be- 
come well  established,  for  they  are  naturally  anxious  that  their 
professional  opinion  shall  be  so  well  founded  as  to  secure  their 
being  sustained  by  the  issue  of  events.  They  are  willing  to 
concede  the  unlimited  influence  of  mind  over  matter  in  ex- 
ceptional cases,  and  to  give  due  credit  to  all  well-authenti- 
cated instances  of  mental  healing.  But  the  failures  of  mental 
practice  are  still  too  common,  and  most  of  the  reports  of  cures 
said  to  be  effected  are  entirely  too  unreliable  to  deserve  con- 


ORIFICIAL    SURGERY.  515 

sideration.  In  determining  the  exact  value  of  mental  thera- 
peutics in  the  treatment  of  disease,  there  is  one  position  which 
they  will,  therefore,  in  all  fairness  be  able  to  sustain,  and  that 
is  that  the  condition  of  the  patient,  both  before  and  after 
treatment,  shall  be  estimated  by  the  same  standards  of  diag- 
nosis as  are  employed  in  passing  judgment  upon  their  own 
work.  It  must  not  be  forgotten  that  this  estimate  includes 
both  objective  and  subjective  symptoms.  The  subjective 
symptoms,  which  are  merely  matters  of  self-conscionsness  on 
the  part  of  the  patient,  by  no  means  furnish  reliable  testi- 
mony as  to  the  presence  or  absence  of  morbid  physical  condi- 
tions. Only  by  a  careful  invoice  of  objective  bodily  phe- 
nomena as  well  both  before  and  after  treatment,  determined 
by  universally  recognized  means  of  physical  diagnosis,  can  an 
adequate  record  be  obtained  of  what  has  and  what  has  not 
been  accomplished.  In  this  respect  the  laity  are  weak,  and 
their  testimony  as  to  the  practical  value  of  all  remedial  meas- 
ures is  perfectly  unreliable.  They  may  claim  to  have  been 
cured  of  consumption,  of  cancer,  of  tumors,  of  paralysis,  or 
of  other  troubles,  but  they  are  not  sufficiently  familiar  with  the 
characteristics  of  any  form  of  disease  to  be  able  to  state,  with 
any  degree  of  reliability,  the  real  nature  of  the  trouble  for 
which  they  were  treated,  or  whether  or  not  a  cure  has  really 
been  effected.  It  is  a  singular  fact  that  mental  healers  do  not 
seem  to  realize  that  the  evidences  of  their  work  are  furnished 
them  only  by  sense  uneducated  itself,  and  when  employed  with 
unpracticed  and  uneducated  faculties  it  is  very  liable  to  be 
erroneous.  The  diagnosis  of  disease  can  only  be  made  by  those 
who  are  thoroughly  educated  and  skilled  in  its  characteristics. 
So  that  the  only  testimony  as  to  what  has  been  cured  and 
what  has  not  by  mental  healing  would  naturally  be  the  testi- 
mony of  the  medical  experts  themselves.  Bodily  sensations 
may  be  changed  by  suggestive  measures,  but  this  does  not 
necessarily  involve  a  change  in  existing  pathology.  Mere  im- 
pressions and  self-told  tales  by  patients  themselves  are  per- 
fectly valueless  from  a  scientific  standpoint,  although  an  im- 
proved state  of  bodily  sensations  and  physical  comfort  may 


516  ORIFICIAL    SURGERY. 

allure  and  deceive  those  who  are  uneducated  in  correct  meth- 
ods of  diagnosing  physical  conditions. 

The  difference  between  the  conscious  and  unconscious 
mind  should  not  be  overlooked  or  ignored.  The  subjective 
part  of  human  suffering  can  undoubtedly  be  reached  by  sug- 
gestive therapeutics,  as  this  is  merely  a  matter  of  self-con- 
sciousness. It  is  said  that  the  human  mind  can  entertain  but 
one  idea  and  its  associate  ideas  at  the  same  time.  Now,  the 
sick  who  are  constantly  complaining  of  some  form  of  discom- 
fort are  universally  illogical  in  the  selection  of  the  idea  which 
they  consent  to  entertain.  In  matters  outside  of  themselves 
they  are  sensible  enough  in  their  pursuits  to  give  their  atten- 
tion to  and  direct  their  footsteps  in  the  pursuit  of  whatever 
may  be  the  object  of  their  desires.  Perhaps  they  have  lost 
something.  It  takes  no  doctor  to  convince  them  that  the  way 
to  find  it  is  to  hunt  for  it,  and  to  the  neglect  of  everything 
else  the  energies  of  their  mind  and  body,  and  sometimes  those 
of  t^eir  friends,  are  at  once  enlisted  in  the  search  for  the  lost. 
But  in  matters  of  bodily  economy  they  are  so  singularly  il- 
logical as  to  completely  ignore  this  very  common  sense  pro- 
ceeding. If  they  have  lost  their  health  and  become  conscious 
of  any  variety  of  distress  in  consequence,  instead  of  focusing 
their  powers  of  mind  on  the  health  which  they  have  lost  and 
confining  their  attention  to  what  should  be  the  legitimate  ob- 
ject of  their  search  until  they  have  again  secured  it,  they  in- 
variably proceed  to  take  an  invoice  of  every  ache  and  pain 
which  invites  their  attention;  and,  as  their  sufferings  increase 
under  the  stimulation  of  their  search — for  why  should  they 
not  find  what  they  look  for — they  enlist  the  services  of  others 
about  them,  doctors  and  nurses  included,  to  help  them  in  giv- 
ing attention  to  the  very  thing  which  they  do  not  want,  name- 
ly, the  discomfort  which  has  come  upon  them.  Now,  it  is  im- 
possible to  push  and  pull  at  the  same  moment.  Neither  can 
one  take  hold  and  let  go  at  the  same  moment.  Nor  can  one 
look  east  and  west  with  the  same  glance.  And  while  one's 
mind  is  steadily  held  upon  the  contemplation  of  health,  it  can- 
not in  the  same  instant  be  occupied  with  considerations  of 
sickness,  so  that  if  a  suggestion  of  what  is  desirable  can  be 


ORIFIG1AL   SURGERY.  517 

firmly  grasped  by  the  mind  of  the  patient,  he  will  necessarily 
lose  consciousness  of  everything  that  is  undesirable,  and  his 
former  pain  will  pass  away,  for  in  all  cases  pain  and  discom- 
fort of  all  kinds  are  mere  matters  of  attention  and  recogni- 
tion. To  illustrate  to  what  extent  mental  concentration  shapes 
history,  listen  for  a  moment  to  the  narration  of  two  simple 
incidents  of  comparatively  recent  occurrence. 

A  resident  of  one  of  the  suburbs  of  Chicago,  having  a 
fondness  for  animals,  secured  a  fine  kennel  of  dogs,  consisting 
of  three  fox  terriers,  two  greyhounds,  two  St.  Bernard  pups, 
weighing  150  pounds  apiece,  and  a  beautiful  collie.  There  was 
no  cat  on  the  premises,  but  it  was  the  fault  of  the  dogs,  for 
they  had  no  respect  for  cats  and  considered  them  merely  as 
their  legitimate  prey.  It  was  the  delight  of  the  greyhounds 
to  tree  them  in  their  morning  excursions  with  whatever 
equipages  were  in  use,  while  it  seemed  to  furnish  keen  de- 
light to  the  fox  terriers  to  tear  them  to  pieces  whenever  the 
opportunity  presented  itself.  The  good-natured  St.  Bernards 
and  the  friendly  collie  expressed  their  good-fellowship  with 
the  other  dogs  by  simply  joining  in  any  cat-hunt  which  they 
might  institute. 

On  a  beautiful  Sunday  morning,  when  all  of  the  dogs 
were  assembled  in  the  carriage  part  of  the  barn,  patiently 
waiting  for  something  worthy  of  their  attention  to  present 
itself,  an  innocent-minded,  simple-hearted,  inoffensive  two- 
thirds  grown  kitten,  leisurely  entered  the  open  door  and  ap- 
proached the  dogs  with  the  intention  of  joining  their  company. 
It  chanced  that  the  kitten  had  not  been  raised  among  her  kind, 
but  had  been  in  constant  association  since  her  babyhood  with 
a  company  of  friendly  dogs,  among  whom  her  lot  had  been 
cast.  Dogs!  why,  she  just  loved  dogs!  Dogs  were  her 
friends;  and  she  seemed  pleased  at  this  new  opportunity  of 
demonstrating  her  friendliness  for  them.  Before  the  dogs  had 
time  to  recover  from  their  astonishment  at  the  audacity  of 
the  new  arrival  in  their  midst,  the  little  thing  walked  right  up 
to  one  of  the  big  St.  Bernards  and  began  to  rub  her  side 
against  the  big  legs  of  the  animal  and  give  expression  to  her 
friendly  sentiments  in  true  cat  fashion.  The  greyhounds, 


518  ORIFICIAL    SURGERY. 

whose  experience  with  cats  had  always  been  in  the  chase, 
with  the  cats  in  the  lead,  pricked  up  their  ears  and  patiently 
waited  for  the  kitten  to  start  on  the  run,  holding  themselves 
ready  to  take  after  it.  The  kitten,  receiving  no  attention  from 
the  St.  Bernard,  observed  the  expectant  attitude  of  the  grey- 
hounds, but  misinterpreted  their  hostile  intentions  for  playful- 
ness, so  that  instead  of  running  from  them  it  began  to  walk 
toward  them.  Having  heretofore  merely  chased  cats,  and  be- 
ing entirely  unaccustomed  to  facing  them,  they  did  not  know 
what  to  make  of  the  new  situation  in  which  they  were  placed, 
and  as  the  kitten  did  not  seem  to  be  afraid  of  them  they  be- 
came afraid  of  the  kitten,  and  backed  away  as  fast  as  they 
were  approached.  By  this  time  the  three  fox-terriers  had 
closed  around  the  poor  little  kitten  from  behind,  and  were 
about  to  pounce  upon  it  when  they  were  observed  by  the  in- 
truder. Recognizing  in  dogs  no  sentiment  but  friendliness, 
and  with  its  little  cat  mind  thoroughly  imbued  with  the  spirit 
of  good-fellowship,  the  little  trustful  kitten  stopped  following 
the  greyhounds  and,  while  the  interested  collie  stood  patiently 
waiting  for  the  excitement  to  begin,  in  a  spirit  of  playfulness 
turned  its  attention  to  the  fox  terriers.  These  cat-destroyers 
were  so  dumbfounded  at  the  audacity  of  the  kitten  that  be- 
fore they  had  time  to  recover  from  their  surprise  the  kitten 
began  playing  with  them  in  a  most  cordial  manner. 

The  contagion  of  good  will  which  the  kitten  brought  with 
it  completely  overcame  all  opposite  sentiments  in  the  breasts 
of  every  member  of  this  pack  of  cat  hunters,  and  the  kitten 
was  duly  initiated  into  their  good  graces  and  permanently  es- 
tablished as  one  of  their  fast  friends.  Cats  suffered  and  died 
at  the  hands  of  these  dogs  afterwards  as  they  had  done  be- 
fore, but  this  specimen  of  the  feline  tribe  was  an  exception, 
and  was  always  welcome  and  safe  in  their  midst.  Upon  the 
morning  of  its  introduction  to  them,  if  a  single  suspicion  of 
distrust  or  fear  had  entered  the  mind  of  the  kitten,  if  a  single 
hair  along  its  spine  had  become  erect,  or  its  tail  grown  one 
bit  larger,  if  it  had  spit  just  once,  or  expressed  the  slightest 
trace  of  antagonism  to  the  dogs  in  any  form  of  cat  language, 
that  Sunday  morning  would  have  been  its  last  on  earth.  But 


ORIFIC1AL   SURGERY.  519 

its  implicit  trust  in  the  honorable  intentions  of  dog  nature  and 
its  fidelity  to  its  memory  of  all  the  good  things  it  knew  about 
dogs,  saved  its  life  and  made  playmates  of  beasts  to  whom 
friendly  sentiments  toward  cats  were  a  new  sensation. 

In  the  next  incident  the  dominant  idea  was  not  so  happily 
chosen.  The  night  was  dark.  One  of  the  professors  of  this 
college  was  driving  his  faithful  horse  north  on  Racine  ave- 
nue. As  the  sides  of  the  street  were  rough  and  there  were  no 
cars  in  sight,  the  horse  was  driven  for  a  short  distance  along 
the  car  tracks,  and  just  as  the  doctor  was  approaching  the 
corner  of  Fullerton  avenue,  and  before  he  had  time  to  guide 
the  horse  to  the  side  of  the  street,  an  approaching  cable  car, 
with  its  headlight  glaring  in  front  of  it,  turned  the  corner  and 
bore  down  upon  him.  The  light  immediately  attracted  the 
attention  of  the  horse,  which,  instead  of  obeying  its  master 
and  dragging  him  out  of  harm's  way,  suddenly  stopped  right 
in  the  middle  of  the  track,  not  from  malice  (for  the  horse  was 
not  a  balky  one),  but  simply  because  its  gaze  was  so  thor- 
oughly fixed  by  the  headlight  of  the  approaching  train  that  it 
lost  all  conscionsness  of  everything  else.  The  doctor  used  the 
whip  freely  and  shouted  with  all  his  might,  but  the  horse  was 
too  thoroughly  occupied  with  his  new  concept  to  heed  his  mas- 
ter's voice  or  his  blows.  With  cruel  speed  on  came  the  train, 
but  the  horse,  unmoved  by  any  sense  of  danger  or  by  the  ap- 
peals of  his  master,  stood  motionless  on  the  tracks  over  which 
the  train  must  pass.  The  gripman  appreciated  the  situation 
too  late  to  prevent  a  collision.  There  was  a  heavy  thud,  the 
doctor,  badly  shaken  up,  was  entangled  in  the  ruins  of  his 
phaeton,  and  the  horse  was  killed  by  the  shock,  dying  as  the 
victim  of  an  unfortunate  concentration  of  attention  to  an 
approaching  danger.  Had  it  given  heed  to  its  master's  bid- 
ding, instead  of  surrendering  to  its  fears,  the  catastrophe 
would  have  been  averted. 

These  two  incidents  illustrate  the  power  of  an  idea  for 
good  or  for  harm;  and,  although  they  occurred  in  animals, 
the  principle  involved  in  the  incidents  operates  with  equal 
force  in  human  experience.  "As  a  man  thinketh  in  his  heart 
so  is  he."  Whatever  idea  succeeds  in  establishing  a  dominat- 


520  OBlFICIAL    SURGERY. 

ing  influence  in  the  mind  of  man  at  any  time  dictates  the  di- 
rection of  his  self-consciousness  and  makes  good  or  bad  his- 
tory, according  to  its  quality.  For  this  reason  the  conscious 
mind  is  a  fertile  field  for  the  practice  of  suggestive  therapeu- 
tics. And  when  it  becomes  universally  recognized  that  joys 
and  sorrows,  and  pleasures  and  pain,  and  happiness  and  mis- 
ery, and  delights  and  tribulations,  and  all  other  states  of  self- 
consciousness  are  matters  merely  of  attention  and  cultivation, 
there  will  be  less  pride  in  suffering  and  more  in  enjoying,  less 
sympathy  for  the  sick  and  more  appreciation  for  the  healthy. 

The  physical  world  appears  at  first  thought  to  be  one 
great  accumulation  of  fixed  facts,  which  we  may  all  enjoy  or 
suffer  in  common,  but  in  reality  there  are  as  many  physical 
worlds  on  our  small  planet  as  there  are  people  who  cling  to 
its  surface,  for  all  the  world  there  is,  to  any  living  being,  is 
merely  the  world  of  his  own  self-consciousness;  and  as  no  two 
individuals  are  alike  in  their  observations  and  mental  photo- 
graphs of  things,  so  there  are  no  two  world  pictures  which  are 
identical. 

There  is  no  light  for  those  who  are  blind,  there  is  no  sound 
for  those  who  are  deaf,  there  is  no  odor  for  those  who  have 
no  sense  of  smell,  there  is  no  flavor  for  those  who  are  devoid 
of  the  sense  of  taste,  and  there  is  no  contact  with  anything  on 
earth  to  those  who  are  without  the  sense  of  touch.  Those  who 
have  neither  sight,  nor  hearing,  nor  smell,  nor  taste,  nor  touch 
are  practically  dead,  so  far  as  earthly  existence  is  concerned, 
and  for  them  there  is  no  physical  world.  But  the  power  to  ob- 
serve, through  the  various  senses,  does  not  lie  in  the  physical 
organs  themselves,  but  in  the  faculties  which  created  these 
organs;  and  as  they  operate  merely  under  the  stimulus  of  at- 
tention, or  suggestion,  if  you  will,  all  the  material  world  that 
exists  for  any  one  of  us  is  merely  the  one  which  we  have  pho- 
tographed through  our  various  senses.  This  fact  gives  great 
variety  to  the  material  worlds  as  they  exist  for  each  one  of  us ; 
indeed,  makes  them  as  numerous  as  mankind  itself.  For  some, 
it  is  a  place  of  sickness,  and  suffering,  and  disappointment,  and 
anguish,  and  failure,  and  death.  For  others,  it  is  bright,  beau- 
tiful, radiant,  glorious,  delightful.  For  some,  it  is  a  hard  world 


ORIFIC1AL    SURGERY.  521 

of  stern  necessity,  furnishing  nothing  but  an  eternal  grind  for 
something  to  eat,  something  to  wear,  and  a  place  in  which  to 
sleep.  For  others,  it  is  a  land  of  wealth,  and  prosperity,  and 
beauty,  and  happiness.  Some  would  like  to  remain  here  al- 
ways, while  for  some  it  is  but  a  waiting-station,  where  they  are 
trying  to  kill  time  until  summoned  by  the  inevitable  course  of 
events  to  leave  it. 

In  view  of  this  situation,  it  is  a  matter  of  extreme  im- 
portance what  photographs  we  take  with  our  various  facili- 
ties, what  pictures  of  things  about  us  we  make  and  hang  on 
memory's  walls.  Our  tastes  and  inclinations  are  clearly  dem- 
onstrated by  the  collection  which  we  accumulate.  Seek  and  ye 
shall  find,  knock  and  it  shall  be  opened  unto  you,  are  sayings 
wonderfully  broad  in  their  scope  of  application,  for  they  ap- 
ply to  all  the  details  of  every-day  life.  How  important  it  is, 
then,  for  us  to  seek  for  the  desirable  and  to  withdraw  our  at- 
tention from  the  undesirable ;  to  be  guided  in  our  observations 
by  hope  and  trust,  and  refuse  to  recognize  the  things  we  fear 
and  wish  to  avoid !  Any  one  who  has  ever  ridden  a  bicycle  ap- 
preciates the  importance  of  this  suggestion,  for  concentrated 
attention  upon  an  obstruction  which  a  rider  may  be  nearing 
invites  a  collision.  The  unfortunates  of  life  are  merely  those 
who  are  perpetually  taking  headers  upon  the  undesirable,  sim- 
ply because  they  fail  to  recognize  this  universally  prevailing 
principle  of  human  progress — that  we  approach  and  are  more 
or  less  influenced  by  the  objects  of  our  attention.  To  seek 
what  one  wants  seems  a  mere  matter  of  common  sense,  for  how 
shall  we  find  what  we  do  not  look  for?  We  can  never  find 
health  by  hunting  for  disease.  There  is  all  the  difference  in 
the  world  between  helping  the  Lord  and  fighting  the  devil.  By 
the  one  act  we  are  ushered  into  the  heaven  of  our  satisfaction, 
and  by  the  other  into  the  hell  of  our  disappointment. 

The  psychic  factor  dominates,  indeed  includes,  the  faculty 
of  observation,  and  therefore  acts  for  the  great  unerring  power 
as  a  producer  of  concepts,  whose  accumulation  makes  each  in- 
dividual world  picture.  There  is  no  pain,  no  disease,  no  death 
to  him  who  fails  to  recognize  them,  and  much  of  the  confusion 
in  the  debates  constantly  arising  concerning  material  entities, 


522  OKIFIC1AL   SURGERY. 

has  its  origin  merely  in  unequal  observation.  We  know  that 
our  various  physical  faculties  are  many  times  more  or  less  de- 
fective. Our  eyes  frequently  mislead  us  as  to  the  size,  shape 
and  color  of  things.  Our  ears  sometimes  trick  us  with  false  re- 
ports concerning  what  is  heard,  and  our  other  organs  of  special 
sense  are  fully  as  prone  as  these  to  bear  false  witness.  Like 
other  telephones  our  organs  of  sense  will  sometimes  get  out  of 
order.  Nevertheless,  we  have  standard  tests  by  which  to  gauge 
the  condition  of  our  organs  and  correct  all  deviations  from  a 
normal.  So  that  for  all  practical  purposes  the  testimony  of 
our  senses  is  reliable,  the  difference  between  the  impressions 
received  being  due,  not  to  our  physical  organs,  but  to  the  dif- 
ferent objects  for  which  they  are  employed.  This  fact  gives 
great  variety  of  opinion  as  to  the  physical  entities,  and  at  the 
same  time  may  cause  some  one  to  wonder  why  it  is  that  physi- 
cal creations  seem  so  fixed  and  substantial.  There  is  a  reason 
for  this,  and  it  lies  in  the  kinship  of  mankind  and  the  conse- 
quent common  directions  in  which  the  powers  of  observation 
are  directed.  The  thought  is  perhaps  best  expressed  in  that 
thrilling,  heart-warming,  sustaining  and  harmonizing  sentence 
so  often  quoted,  "The  fatherhood  of  God  and  the  brotherhood 
of  man. ' '  What  is  common  to  us  all  we  recognize  and  seem  to 
understand,  and  consequently  believe  in.  Experiences  of  an 
individual,  when  unique  and  unheard  of,  are  credited  as  mere 
fancies,  perhaps  because  they  are  such,  and  perhaps  because 
their  strangeness  prevents  their  recognition  as  possible  veri- 
ties. But  as  all  our  world  pictures  are  furnished  by  our  physi- 
cal senses,  these  are  our  sole  reliance  for  all  we  know,  not  only 
of  life  and  of  health,  but  also  of  disease,  of  remedies,  of  cures, 
and  of  death.  Whatever  changes  our  self-consciousness,  there- 
fore, changes  our  knowledge  of  things.  We  are  always  more 
or  less  open  to  suggestion,  so  that  whatever  is  able  to  secure 
our  attention  is  registered  as  knowledge.  External  objects  can 
do  this,  and  those  whose  attention  is  dedicated  to  the  signs  of 
things  merely  are  especially  and  constantly  susceptible  to  any- 
thing and  everything  that  appeals  to  the  senses.  For  this  rea- 
son, physical  measures  can  be  employed  as  means  of  diversion, 


ORIFIG1AL    SURGERY.  523 

and  consequent  cure;  for  the  cure  of  pain  lies  in  its  forget- 
fulness. 

Now,  the  question  of  importance  to  us  is,  can  internal 
forces,  all  of  which  consist  of  some  varieties  of  thought  and 
feeling,  do  the  same  thing  ?  Let  us  particularize  so  as  to  more 
fully  appreciate  the  meaning  and  application  of  the  question 
before  us.  Ether  or  chloroform  can  completely  destroy  con- 
sciousness without  depriving  the  body  of  its  sustaining  life. 
Can  suggestion  do  as  much?  Yes,  it  can;  and  many  a  capital 
operation  has  already  been  painlessly  performed  under  the  in- 
fluence of  steady  and  intense  suggestion.  There  are  drugs 
which  will  allay  pain,  some  of  them  acting  generally  by  be- 
numbing all  sensibility  of  the  body,  such  as  morphine,  codine, 
phenacetine,  etc.,  others  acting  specifically,  as  ipecac  for  nau- 
sea, colocynth  for  abdominal  cramps,  doscorea  for  bilious  colic, 
digitalis  for  palpitation  of  the  heart,  belladonna  for  headache, 
bryoma  for  pleuritic  pains,  etc.  Now,  have  drlugs  in  both  their 
general  and  specific  actions  upon  bodily  conditions  their  sug- 
gestive counterparts?  Most  certainly  they  have,  especially  in 
people  who  can  surrender  themselves  to  their  operation,  for 
the  success  of  suggestion  depends  to  a  great  extent  upon  the 
power  of  mental  concentration.  Instances  of  this  are  so  fre- 
quent as  of  necessity  to  be  more  or  less  frequently  observed 
by  all  of  us.  Drugs  can  allay  fever,  although  they  frequently 
fail,  possibly  because  poorly  selected.  The  record  of  the  action 
of  mental  forces  clearly  demonstrates  that  they  also  can  allay 
fevers  and  subdue  inflammations.  Indeed,  if  one  but  reflects 
upon  the  matter,  it  is  the  play  of  disordered  psychic  forces  that 
produces  confusion  among  the  tissues  of  the  body  and  makes 
fever  possible.  One  cannot  blister  or  inflame  a  corpse,  and 
nothing  but  the  element  of  life  can  produce  such  bodily  con- 
sternation as  to  inflame  tissues,  either  generally  or  locally.  Now 
if  psychic  forces  can  induce  fever,  and  if  it  is  possible  to  con- 
trol their  action  to  one's  liking,  they  should  in  all  reason  be 
equally  efficacious  in  resolving  inflammations  and  subduing 
fevers. 

In  this  way  we  might  go  on  indefinitely  through  a  long  list 
of  human  ailments  of  which  the  body  is  conscious,  and  still 


524  ORIFIG1AL    SURGERY. 

further  emphasize  the  fact  that  the  cure  of  conscious  ailments 
among  human  sufferers  is  in  all  cases  accomplished  by  a  re- 
adjustment of  indwelling  forces,  whether  the  remedy  employed 
be  a  drug  or  a  thought.  The  comparative  merits  of  the  two 
forms  of  treatment  is  too  extensive  a  subject  for  considera- 
tion this  evening.  As  truth,  however,  is  never  inconsistent  with 
itself,  it  is  safe  to  conclude  that  the  various  measures,  be  they 
physical  or  mental,  which  have  been  found  beneficial  in  any 
form  of  sickness  will  not  quarrel,  and  there  is  no  reason  why  it 
should  not  be  as  legitimate  medical  practice  to  think  away  dis- 
ease as  to  exterminate  it  by  drug  action,  and  where  either  alone 
may  prove  insufficient  to  employ  both  methods  at  the  same  time. 
But  what  of  the  unconscious  mind  and  its  more  serious 
troubles  of  organized  pathology?  Suggestion  may  divert  the 
attention  of  the  conscious  part  of  a  sufferer  until  its  spell  serves 
as  an  anodyne  and  allays  pain,  relieves  the  superficial  symp- 
toms of  disease,  and  corrects  the  various  forms  of  functional 
derangements.  But  can  the  soul  in  its  innermost  depths  be  so 
stirred  and  purged  of  its  impurities,  inherited  and  acquired,  as 
to  dissolve,  disintegrate,  and  remove  all  physical  traces  of  a 
well  recognized  serious  malady,  so  that  when  the  case  is  sub- 
jected to  the  standard  tests  of  physical  exploration,  a  radical 
cure  can  be  truthfully  pronounced  to  have  been  effected?  Can 
the  intellectual  and  emotional  nature  of  one  whose  system  has 
taken  on  the  physical  expression  of  cancer,  consumption, 
syphilis,  scrofula,  rheumatic  gout,  or  any  of  the  deep-seated 
constitutional  maladies  usually  so  fatal  in  their  results,  be  so 
tuned  to  harmonious  and  health-giving  action  by  processes  of 
suggestion  as  to  restore  physical  perfection  and  completely 
eliminate  the  deadly  poisons  and  all  traces  of  their  existence 
from  the  tissues  of  the  body?  Can  mental  healing  reach  the 
children  ?  Can  it  cure  the  insane  ?  It  is  not  so  important  that 
the  simpler,  more  superficial  maladies  which  afflict  the  human 
race  should  be  provided  with  a  new  form  of  treatment,  how- 
ever successful  it  may  be,  for  the  measures  already  at  the  com- 
mand of  the  medical  profession  are  quite  serviceable  and  sat- 
isfactory in  these  types  of  disease.  But  where  more  light  is 
needed  and  additional  help  wanted  is  in  the  cases  for  which 


ORIFIG1AL    SURGERY.  525 

at  present  there  appears  to  be  no  adequate  form  of  relief.  Can 
the  sins  of  omission  and  commission,  which  must  be  deep-seated 
to  have  resulted  so  disastrously,  be  so  thoroughly  erased  from 
the  pages  of  the  book  of  life,  which  is  but  another  name  for  the 
unconscious  mind,  as  to  reinvigorate  the  entire  physical  or- 
ganization and  materially  extend  its  period  of  earthly  experi- 
ence? 

As  the  body  is  but  the  effect,  of  which  the  indwelling  life 
or  spirit  is  the  cause,  whatever  condition  it  may  display  must 
of  necessity  stand  for  soul  habits  or  realities.  A  careful  analy- 
sis of  the  spiritual  organization  of  man  resolves  it  into  two 
primal  elements,  namely,  thoughts  and  emotions;  and  if  mis- 
chief of  any  type  whatsoever  appears  in  bodily  expression,  it 
must  be  the  fault  of  either  the  head  or  the  heart.  The  specific 
cause  of  the  difficulty  may  prove  difficult  to  trace  in  any  given 
case,  for  the  depths  of  life  are  fathomless  and  dark,  and  diffi- 
cult of  exploration.  But  of  one  thing  we  can  be  certain,  that 
the  hope  for  a  radical  cure  of  physical  pathology  lies  in  the  di- 
rection of  soul  purification.  We  want  so  much  that  proves  to 
be  bad  for  us,  and  our  wits  are  so  thoroughly  dedicated  to  the 
service  of  our  heart's  desires,  that  we  can  scarcely  hope  to  ef- 
fect radical  cures  of  constitutional  maladies  by  physical  meas- 
ures alone.  The  axe  must  be  laid  at  the  root  of  the  tree,  which 
means  that  the  mistakes  and  errors  of  the  inner  life  must  be 
reached  and  corrected  before  complete  healing  is  secured. 

So  let  us  extend  a  hearty  welcome  to  all  forms  of  sub- 
stantial progress.  Doctors  in  general  may  be  a  little  appre- 
hensive that  their  equipment  of  physical  knowledge  and  para- 
phernalia for  the  treatment  of  disease  may  lose 'their  due  ap- 
preciation, and  their  prospects  for  useful  and  successful  lives 
be  thus  seriously  injured.  But  there  is  really  no  occasion  for 
alarm  in  this  direction :  for  truth,  when  once  born  into  the 
world,  is  never  lost,  and  all  that  has  proved  serviceable  in 
their  work  will  always  be  needed  so  long  as  the  conditions 
which  call  for  it  prevail. 

There  is  such  a  thing  as  thought-transference  or  telepathy. 
Its  operation  is  more  rapid  than  light  or  electricity,  or  any 
other  force  of  which  we  have  any  knowledge.  Unconsciously, 


526  ORIFIC'IAL    SURGERY. 

it  is  in  active  operation  at  all  times  and  among  all  people,  but 
its  existence  is  usually  unrecognized,  and  although  a  few  prac- 
ticed experts  have  been  able  in  some  cases  to  make  practical 
use  of  this  power  for  definite  purposes  of  communication,  nev- 
ertheless the  science  of  conscious  thought-talking  is  certainly 
in  its  infancy.  Should  it,  however,  finally  become  developed 
and  be  available  for  everyday  use,  would  it  necessarily  para- 
lyze the  business  of  the  great  ocean  cables  of  the  world  or  dis- 
pense with  the  telegraph  or  telephone  wires?  The  invention 
of  wire-talking  has  by  no  means  dispensed  with  written  com- 
munications, and  lip  service  and  the  mail  service  of  every 
country  is  still  thriving,  and  private  and  public  oratory  seem 
just  as  necessary  as  a  means  of  communication  as  ever. 

Analagous  to  these  same  lines  of  progress  has  been  the 
growth  and  development  of  medical  practice.  The  new  light 
which  has  evidently  come  into  the  entire  world  is  flooding  the 
practice  of  medicine  as  it  is  all  the  other  activities  and  occu- 
pations of  men. 

The  psychic  factor  at  last  demands  recognition,  study  and 
appreciation.  Nevertheless,  the  enjoyment  of  health  as  well 
as  the  affliction  of  sickness  is  almost  universally  ascribed  to 
external  conditions.  The  environment  of  the  individual  is 
held  by  almost  everybody  as  responsible  for  whatever  develop- 
ments occur  in  the  history  of  physical  existence:  whereas  in 
all  cases  it  is  not  what  happens,  but  the  interpretation  of  what 
happens  that  is  responsible  for  history.  The  challenge  to  be 
sick,  with  visible  excuse,  lies  everywhere  about  us  at  all  times. 
The  acceptance  of  the  challenge,  the  surrender  to  its  influence, 
lies  purely  with  the  conditions  of  the  individual  at  all  times. 
The  element  of  susceptibility  seems  to  have  been  overlooked 
by  professional  diagnosticians,  notwithstanding  the  fact  that 
under  identically  the  same  conditions  no  two  individuals  mani- 
fest the  same  inclinations  or  secure  the  same  results.  No  ade- 
quate explanation  has  ever  been  offered  for  the  great  fact  that 
what  is  one  man's  meat  is  another  man's  poison. 

But  disease,  like  health,  is  not  from  without,  but  from 
within,  and  this  unconsidered  element  of  susceptibility,  the 
personal  and  yet  unconscious  interpretation  of  the  incidents 


OBIFIC1AL    SURGERY.  527 

and  accidents  of  time,  which  alone  is  responsible  for  the  history 
of  every  event  which  is  etched  into  bodily  expression,  is  at 
last  looming  into  importance,  and  demonstrating  the  necessity 
of  suggestive  therapeutics  as  a  long-needed  supplement  to 
physical  medicine. 

The  phrase,  supplement  to  physical  medicine,  is  used  ad- 
visedly. For,  whereas,  the  order  of  creation  is  unquestionably 
from  within  outward,  our  knowledge  of  it  must  always  proceed 
from  without  inward.  We  undoubtedly  came  from  an  unsensed 
shore.  But  all  the  knowledge  of  that  shore  which  we  can  ob- 
tain in  this  world  will  be  by  means  of  knowledge  furnished  us 
by  the  senses  themselves,  and  while  we  linger  on  earth  we  will 
never  be  able  to  dispense  with  their  services. 

We  obtain  a  knowledge  of  the  letters  of  the  alphabet 
from  the  picture-blocks  of  childhood,  and,  although  later  on  we 
learn  to  spell  out  the  whole  dictionary  of  words  in  which  are 
crystallized  all  the  knowledge  of  this  world  or  the  next  which 
we  ever  come  to  possess,  we  never  forget  our  letters,  nor  can 
we  dispense  with  them.  We  may  acquire  other  means  of 
communication,  may  talk  by  sounds  or  signs,  or  even  by 
thought  transference,  but  written  language,  with  its  familiar 
words  and  more  familiar  letters,  will  be  a  human  necessity 
throughout  all  time. 

As  well,  there  can  be  no  lasting  science  in  metaphysics 
which  does  not  rest  as  a  basis  upon  correct  principles  of 
physics.  This  is  a  sweeping  proposition,  and  true  in  its  every 
possible  application. 

Bringing  it  home  to  the  subject  under  discussion  tonight, 
we  are  forced  to  the  conclusion  that,  although  a  human  soul 
is  undoubtedly  the  active  force  which  has  constructed,  from 
materials  furnished  by  the  earth,  every  human  form  that  has 
ever  been  projected  into  the  realm  of  time  and  space,  and  al- 
though the  soul  continues  as  the  active  agent  of  continued 
earthly  existence  and  is  responsible  for  every  form  of  it,  be  it 
that  of  health  of  disease,  nevertheless  there  can  be  no  accurate 
knowledge  of  soul-formation,  of  soul-physiology,  or  of  soul- 
pathology,  or  no  specific  and  enduring  form  of  soul-medica- 
tion or  soul-treatment  that  does  not  issue  from  corresponding 


528  ORIFICIAL    SURGERY. 

physical  knowledge.  And  just  so  long  as  the  alphabet  of  our 
childhood  will  be  needed  in  the  language  of  the  race,  without 
regard  to  the  degree  of  wisdom  to  which  it  may  ultimately  at- 
tain, so  will  every  well-established  fact  known  to  the  physical 
practice  of  medicine  be  always  retained  as  a  necessary  basis 
for  whatever  knowledge  of  the  higher  medicine  may  ultimately 
come  into  our  possession.  For  this  reason,  practitioners  of 
physical  medicine  must  of  necessity  become  the  most  scientific 
and  successful  spiritual  practitioners  of  the  future,  and  the 
greater  and  more  accurate  their  knowledge  of  the  human  body 
and  its  operations,  and  of  the  various  physical  measures  found 
useful  in  accomplishing  physical  repairs,  the  more  accurate, 
detailed  and,  consequently,  serviceable  may  their  knowledge 
of  spiritual  conditions  and  new  remedies  become. 

For  the  present,  it  but  remains  to  remind  those  who  seem 
imbued  with  the  desire  to  ignore  all  physical  knowledge  in 
their  search  for  the  underlying  principles  of  truth  which  are 
expected  to  be  a  panacea  for  human  ills,  that  when  in  any  of 
our  processes  of  evolution  we  retire  completely  from  the  ac- 
cumulated facts  of  sense  perception  as  a  basis  of  scientific 
work,  we  at  the  same  time  effect  our  complete  exit  from  earth 
and  leave  our  physical  world  behind  us,  in  which  case  the 
search  for  healing  truths  will  be  no  longer  necessary,  for  then, 
we  arp  told,  "there  shall  be  no  more  sickness  nor  death, 
neither  sorrow  nor  crying,  for  the  former  things  are  passed 
away." 

In  the  meantime,  let  us  go  on  with  our  medical  studies, 
let  us  learn  all  we  can  of  physical  aids  to  the  cure  of  disease. 
It  requires  a  thorough  knowledge  of  arithmetic  and  algebra 
and  geometry  and  trigonometry  to  fit  one  for  the  study  of  as- 
tronomy. But  without  a  knowledge  of  astronomy,  our  train- 
ing in  mathematics  is  incomplete.  So,  in  addition  to  our 
physical  knowledge,  let  us  welcome  the  new  light  which  is 
come  into  the  world.  It  is  the  astronomy  of  our  medical  math- 
ematics. There  is  nothing  whatever  incompatible  in  the  vari- 
ous forms  of  healing.  In  man  perfect  health  reigns  only  when 
the  objective  and  the  subjective  mind,  or  the  internal  and  the 


ORIFIG1AL   SURGERY.  529 

external,  are  adjusted  to  harmonious  operation;  so,  too,  will 
doctors  become  true  healers  of  diseases  only  when  mental  and 
physical  healing  become  embodied  in  a  single  system  of  active, 
everyday  practice. 


CHAPTER  LXVIII. 


MENTAL  HEALING. 


E.   H.   PRATT,   M.   D. 


Shall  we  ignore  it,  condemn  it,  tolerate  it,  or  make  use  of 
it  and  add  it  to  our  already  long  list  of  legitimate  remedial 
measures  ? 

We  cannot  afford  to  ignore  it,  for  too  large  a  number  of 
patrons  are  deeply  interested  in  it  and  will  not  permit  it  to 
remain  unnoticed.  We  cannot  condemn  it,  for  although  its  sins 
of  omission  are  great,  our  own  shortcomings  unfit  us  for  the 
task  even  if  it  were  otherwise  possible  of  accomplishment.  And 
then,  too,  its  claims  for  recognition,  like  our  own,  are  based 
upon  what  it  has  done  and  not  upon  what  it  has  failed  to  do. 
As  to  its  toleration,  this  will  not  be  a  matter  of  choice  with 
us  for  it  has  evidently  come  to  stay,  and  its  friends  and  advo- 
cates and  defenders  are  too  great  and  too  enthusiastic  a  host  to 
be  downed  by  any  action,  however  concerted,  upon  our  part. 

It  is  certainly  old  enough  to  be  entitled  to  recognition, 
for  mental  healing  has  been  employed  for  the  cure  of  the  sick 
from  a  time  so  long  ago  as  to  be  completely  lost  in  the  vista  of 
the  centuries.  Its  special  claim  to  recognition  in  our  own 
time  lies  in  the  fact  that  it  now  claims  to  be  established  upon 
a  scientific  basis  and  is  no  longer  a  mere  superstition,  a  senti- 
ment, a  religious  fanaticism.  To  be  sure,  there  is  still  a  sect 
of  faith  healers  who  are  as  unscientific  in  their  methods  as 
they  are  uncertain  in  their  results.  But  since  the  time  when 
Swedenborg  spoke  of  human  beings  as  possessed  of  an  internal 
and  external,  and  especially  after  his  analysis  was  copied  by 
the  Christian  Scientists,  only  named  differently,  being  referred 


530  OKIFIC'IAL    SURGERY. 

to  as  the  personality  and  the  individuality,  and  by  Hudson  in 
his  "Law  of  Psychic  Phenomena,"  the  same  distinction  being 
kept  up  under  still  different  titles,  namely,  the  objective  and 
the  subjective  minds,  observation,  reason  and  experiment  have 
been  furnished  with  a  substantial  basis  for  their  operations 
not  previously  enjoyed,  and  the  claim  of  mental  healing  as  a 
scientific  means  of  cure  can  by  no  means  be  considered  as 
absurd. 

Many  of  the  inconsistencies  constantly  encountered  in 
any  individual  experience  between  mental  and  physical  condi- 
tions, and  the  confusion  occasioned  by  observing  the  great  dis- 
crepancies between  mental  fancies  and  physical  facts  can  be 
readily  accounted  for  and  explained  by  recalling  the  double 
nature  of  man,  whether  considered  physically  or  mentally. 

Physically,  the  nervous  system  which  dominates  nutrition, 
which  builds  up  and  tears  down  tissues,  which  presides  over 
functions,  which  blesses  with  health  or  afflcts  with  disease, 
which  ignites  inflammations  and  which  extinguishes  their 
fires,  which  is  responsible  in  fact  for  all  bodily  normalities  and 
abnormalities,  is  the  sympathetic.  Its  activity  is  steady  and 
unremitting  in  its  operation  from  birth  to  death,  through  wak- 
ing and  through  sleeping,  through  work  and  through  play, 
through  calms  and  through  storms,  through  sickness  and 
through  health.  The  action  upon  the  organism  of  the  cerebro- 
spinal  system  is  intermittent,  erratic,  and  for  the  sole  purpose 
of  adjusting  the  individual  to  its  liking  with  reference  to  its 
environment.  By  its  various  senses  it  warns  the  body  of  its 
dangers  and  cognizes  its  delights.  By  the  voluntary  muscular 
system,  which  it  dominates,  it  moves  the  body  about  to  its 
liking,  orders  its  footsteps,  prescribes  its  work  and  its  rest, 
its  smiles  and  its  tears,  and  in  every  way  dominates  its  volun- 
tary activities.  But  there  it  stops.  It  can  blush  or  pale  a 
face,  or  prescribe  bodily  tasks  or  pastimes,  or  work  it  or  rest 
it,  but  it  cannot  nourish  it.  The  cerebro-spinal  system  can 
neither  digest,  circulate,  nor  appropriate  food  nor  dispose  of 
the  debris  from  the  wear  and  tear  of  tissues,  except  secondarily 
as  it  is  able  to  obtain  the  co-operation  of  the  sympathetic  sys- 


ORIFIC1AL    SURGERY.  531 

tern,  which  fortunately  for  mankind,  has  a  mind  of  its  own  and 
is  not  at  all  times  and  in  all  places  at  the  mercy  of  the  ce- 
rebro-spinal  activities. 

The  mind,  or  indwelling  spirit,  which  animates  the  sym- 
pathetic nervous  system,  is  unquestionably  the  subjective  mind 
of  Hudson,  the  individuality  of  the  Christian  Scientists,  or  the 
internal  of  Swedenborg,  while  the  soul  of  the  cerebro-spinal 
system  or  its  vitalizing  principle  is  the  objective  mind  of  Hud- 
son, the  personality  of  the  Christian  Scientists,  or  the  external 
of  Swedenborg.  The  two  natures  of  man,  the  external  and  in- 
ternal, or  the  personality  and  the  individuality,  or  the  ob- 
jective and  subjective,  or  whatever  else  they  be  termed,  are 
always  more  or  less  at  variance  in  every  human  being.  And 
hence  the  incongruities  which  are  constantly  arising  between 
the  fancies  of  the  external,  the  personal,  the  objective  which 
habitates  the  cerebro-spinal  system,  and  the  internal,  indi- 
vidual or  subjective,  which  has  its  dwelling  place  and  finds  its 
bodily  expression  through  the  sympathetic. 

This  is  why  in  serious  illness  many  times  the  faith  and 
trust  deeply  implanted  in  the  sympathetic  nerve  may  serve  to 
effect  a  restoration  to  health  in  spite  of  the  fact  that  the  ce- 
rebro-spinal organization  is  thoroughly  impregnated  with  the 
fear  of  perpetual  illness  or  speedy  death ;  or,  on  the  other  hand, 
how  a  deep-seated  conviction  that  the  end  has  come,  when  op- 
erating through  the  sympathetic  nerve,  can  bring  to  an  untime- 
ly end  all  the  activities  of  the  body,  and  prescribe  death  in 
spite  of  all  the  hopes,  aspirations  and  expectations  entertained 
by  the  spirit  of  the  cerebro-spinal  nervous  system.  In  other 
words,  it  is  our  book  of  life,  the"  unconscious,  the  involuntary, 
internal,  personal,  subjective  part  of  us  that  holds  our  keep- 
ing in  its  hands,  and  prescribes  for  us  our  days  and  conditions, 
that  registers  our  histories  and  unfolds  our  prophecies. 

A  persistent  or  determined  belief  or  desire  on  the  part  of 
the  indwelling  vitality  of  the  cerebro-spinal  system  may,  and 
undoubtedly  many  times  does,  influence  the  course  of  action  of 
the  sympathetic  nerve,  and  in  such  cases  can  affect  the  deep 
issues  of  health  and  disease,  life  and  death.  But  not  necessar- 
ily so.  For  our  judgments,  which  belong  to  the  one,  and  our 


532  ORIFIG1AL    SURGERY. 

intuitions,  which  characterize  the  other,  are  by  no  means  in 
agreement,  however  fierce  the  struggle  for  supremacy.  Women 
sometimes  have  a  mind  of  their  own,  even  if  they  are  married, 
and  the  sympathetic  nerve,  which  stands  for  the  feminine  ele- 
ments of  the  individual,  can  cling  so  closely  to  its  faith  in  how 
things  should  be,  and  how  they  will  be,  in  spite  of  all  the  per- 
suasive eloquence  of  the  more  wilful  nature  which  finds  ex- 
pression through  the  cerebro-spinal  system  as  to  exercise  de- 
cisive action  in  all  measures  of  bodily  economy.  They  say  that 
women  rule  the  world.  Be  this  as  it  may,  it  is  certain  that  in 
the  personal  economy  of  every  human  being  the  sympathetic 
nerve,  which  contains  the  internal,  individual,  subjective,  in- 
tuitive, or  womanly,  part  of  man,  most  emphatically  runs  the 
bodily  household.  Her  plans  may  be  wrecked,  her  activities 
disturbed  by  the  lordly  cerebro-spinal,  but  she  has  a  mind  of 
her  own,  and  she  carries  her  point.  But  it  is  the  separate  and 
distinct  characteristics  of  these  two  parts  of  our  nature  that 
so  often  saves  us  or  ruins  us  in  spite  of  ourselves.  The  cerebro- 
spinal  system  may  fear  indigestion,  but  the  sympathetic  system 
will  scout  the  idea,  and  take  care  of  a  good  dinner.  The  ce- 
rebro-spinal system  may  violate  any  one  or  all  of  the  ten  com- 
mandments to  the  point  of  bodily  annihilation  if  it  had  the 
say  in  the  matter,  while  the  sympathetic  nerve  may  calmly  and 
quietly  follow  a  more  practical  career,  and  shield  the  general 
household  from  the  danger  that  otherwise  would  follow  it.  Or 
the  judgment  of  the  cerebro-spinal  system  may  in  all  sincerity 
of  purpose  issue  bodily  decrees,  which  may  be  easily  set  at 
naught  by  an  opinionated  intuitional  sympathetic.  It  is  only 
united  households  which  stand.  And  it  is  only  where  judg- 
ment and  intuition  agree  that  fancies  will  conform  to  facts, 
and  hopes  and  fears,  and  all  thoughts  and  emotions  in  all  their 
varieties  find  accurate  expression  in  physical  conditions. 

In  all  bodily  repair,  therefore,  this  double  organization  of 
man  must  constantly  be  borne  in  mind,  and  when  the  measures 
employed  are  mental  or  physical  they  can  only  secure  perma- 
nency of  results  as  they  are  able  to  influence  the  action  of  the 
sympathetic  nerve. 


ORIFIG1AL    SURGERY.  533 

That  mental  forces  are  capable  of  exercising  action,  suf- 
ficiently deep-seated  to  affect  the  intuitional  part  of  man's 
nature  which  presides  over  his  functions  and  nutritions,  has 
now  been  demonstrated  so  plainly  and  repeatedly  that  any  one 
who  is  at  all  open  to  conviction  may  easily  become  persuaded 
of  the  fact  by  carefully  conducted  investigation.  In  this  great 
fact  mental  healing  finds  its  excuse  for  existence  and  for  recog- 
nition, and  also  justifies  its  claim  of  a  scientific  basis  of  opera- 
tion, for  all  cures,  be  they  accomplished  through  physics  or 
metaphysics,  are  universally  effected  through  the  agency  of  the 
blood  vessels,  under  the  immediate  command  of  whatever  in- 
fluences the  sympathetic  nervous  S3rstem  to  action. 

Truth  is  never  inconsistent  with  itself,  whatever  be  the 
plane  of  its  manifestation.  College-bred  men  do  not  necessar- 
ily make  poor  farmers,  culture  is  not  inconsistent  with  good 
carpenter  work,  religion  need  not  incapacitate  a  day  laborer 
for  his  toil,  and  a  recognition  of  the  value  of  psychic  forces  in 
curing  disease  by  no  means  depreciates  the  value  of  drags  and 

» 

scalpels.  Physics  and  metaphysics  are  not  rivals;  but  when 
rightly  interpreted  are  mutually  helpful  to  each  other.  Doc- 
tors, perhaps,  have  been  heretofore  too  materialistic  in  their 
ardent  search  for  helps  for  human  ills ;  and,  on  the  other  hand, 
mental  healers  have  made  strenuous  efforts  to  ignore  physical 
aid.  Thus  each  class  of  workers  has  done  more  or  less  in- 
justice to  the  other  class,  and  established  an  unwholesome  ri- 
valry between  measures  which  should  act  in  harmony.  The 
soul  and  the  body  should  not  quarrel,  neither  should  mental 
and  physical  healing;  but  the  scope  of  each  should  be  care- 
fully considered  and  discussed,  and  each  given  its  proper  field 
of  operation,  as  only  by  their  co-operation  can  humanity  ever 
enjoy  emancipation  from  its  ills. 

Both  air  and  soil  are  essential  to  the  growth  of  trees  and 
plants,  and  roots  and  branches  are  not  rivals  but  mutual  helps 
in  plant  development. 

In  a  like  manner  should  physics  and  metaphysics  be  mutu- 
ally helpful.  Any  system  of  cure  that  ignores  the  factor  which 
the  soul  life  of  the  patient  plays  in  the  problem  of  disease  is 
too  superficial  and  elementary  to  be  permanently,  and  in  many 


534  ORIFIC1AL   SURGERY. 

cases  even  temporarily  effective.  On  the  other  hand  a  system 
of  healing  based  purely  upon  suggestion,  if  solely  relied  upon 
in  active  practice  would  soon  find  itself  so  burdened  with 
sins  of  omission  as  to  speedily  bring  it  into  well  deserved  dis- 
repute. While  the  letter  alone  kills  in  the  practice  of  medicine 
as  elsewhere  the  disembodied  spirit  is  too  ghostly  for  earthly 
purposes.  The  letter  must  contain  the  spirit,  and  at  the  same 
time  the  spirit  must  rest  in  the  letter  to  be  of  practical  service 
to  mankind.  Abuse  of  any  organ  of  the  body  may  institute 
pathological  changes  too  deep-seated  for  a  change  of  habits  to 
efface.  Nevertheless  to  ascribe  all  diseases  to  physical  causes 
in  this  age  of  enlightenment  is  both  illogical  and  childish.  The 
psychic  factor  demands  and  must  receive  recognition.  On  the 
other  hand  physical  agencies  are  helps  that  mankind  will  never 
be  able  to  ignore.  Both  mind  and  matter  are  God-made  and 
law-governed,  and  are  so  closely  intertwined  as  to  be  perfectly 
inseparable  in  all  forms  of  bodily  activity,  be  it  in  health  or 
disease.  0 

The  logical  sequence  is  plain.  If  both  mental  and  physical 
forces  are  operative  in  the  production  of  disease  their  combined 
action  is  called  for  in  its  cure.  The  senseless  rivalry  between 
legitimate  curative  agencies  should  be  speedily  cried  down. 
Prejudice,  bigotry  and  intolerance  have  lived  long  enough. 
The  harm  which  they  have  already  accomplished  to  humanity 
is  incalculable,  and  there  is  now  a  crying  need  for  a  broader 
philanthropy  more  in  keeping  with  the  free  spirit  of  the  age. 
Whatever  will  heal  the  sick  should  concern  doctors,  be  it  men- 
tal or  physical ;  and  the  efficacy  of  mental  healing,  properly 
and  scientifically  applied,  especially  when  used  in  conjunction 
with  well  directed  physical  measures,  it  seems  to  us  has  now 
been  so  thoroughly  established  as  to  entitle  it  to  recognition 
as  a  worthy,  accurate,  scientific  and  desirable  aid  in  the  heal- 
ing of  the  sick.  It  belongs  on  our  list  of  legitimate  remedial 
measures,  and  its  study  should  be  prosecuted  with  the  thor- 
oughness and  vigor  which  characterizes  all  our  investigations. 

In  their  struggles  with  disease  and  death  doctors  have  al- 
ways had  a  hard  time  of  it.  Their  victories  have  been  fre- 
quent enough  to  keep  their  consciences  fairly  clear,  so  that 


ORIFICIAL    SURGERY.  535 

the  poor  living  which  the  world  has  given  them  has  seemed  to 
them  well  earned.  But  so  many  times  their  cures  have  been 
merely  temporary,  and  so  often  they  could  not  cure  at  all  but 
only  palliate,  and  besides  this,  the  fact  that  the  great  volume 
of  sickness  is  practically  undiminished,  and  that  nearly  all  the 
deaths  in  the  world,  even  from  a  doctor's  standpoint,  are  pre- 
mature, in  spite  of  the  long-drawn  battle  which  has  lasted 
through  all  time,  keeps  them  constantly  on  the  alert  for  still 
more  effective  weapons  of  warfare.  Doctors  are  hard,  consci- 
entious students,  and  are  constantly  endeavoring  to  improve 
their  methods,  and  are  always  willing  to  endorse  and  make  use 
of  any  measure  of  true  merit  that  will  render  valuable  service 
in  either  curing  or  preventing  disease,  and  just  as  soon  as  they 
are  persuaded  that  suggestive  therapeutics  has  an  available 
and  reliable  healing  power  they  will  be  only  too  glad  to  give 
it  their  hearty  support  and  encouragement,  and  make  use  of  it 
for  all  it  is  worth. 

The  advocates  of  mental  healing  should  be  patient  for 
recognition.  A  too  ready  acceptance  of  every  measure  which 
presumes  to  healing  power  is  by  no  means  desirable,  and  true 
conservatism  on  the  part  of  the  guardians  of  the  public  health 
is  the  only  safe  policy  for  the  people,  because  otherwise  quack- 
ery and  humbuggery  would  be  rampant  and  lead  to  endless 
confusion  and  disappointment,  while  on  the  other  hand  any 
measure  of  true  merit  can  well  afford  to  wait  patiently  and 
undergo  a  sufficiently  long  and  severe  test  at  the  hands  of 
competent  judges  before  receiving  whatever  recognition  its 
real  value  entitles  it  to.  So  many  cure-alls  have  been  tried  and 
found  wanting,  so  many  theories  have  been  so  auspiciously  in- 
augurated and  have  so  ignominiously  failed  to  fulfill  their 
promises  of  relief,  that  every  new  cry  of  lo,  here !  and  lo,  there ! 
is  naturally  looked  upon  with  suspicion,  and  only  upon  the 
presentation  of  proper  credentials  does  any  measure  become 
entitled  to  even  a  trial  of  its  merits. 

The  credentials  of  mental  healing,  however,  are  all  right. 
Its  processes  are  rational,  its  frequent  cures  have  demon- 
strated beyond  the  possibility  of  a  doubt  its  practicality  and 
efficiency.  But  its  failures  are  likewise  numerous,  and  it  has 


536  ORIFIG1AL   SURGERY. 

already  done  much  mischief,  being  guilty,  like  all  other  reme- 
dial measures  that  have  ultimately  come  into  lasting  favor,  of 
many  sins  of  both  omission  and  commission,  so  that  while  it  has 
already  passed  into  quite  universal  recognition  as  a  power 
there  remains  yet  to  be  defined  its  legitimate  sphere  of  appli- 
cation and  its  limitations. 

In  speaking  of  mental  healing  as  a  means  of  cure  we  by 
no  means  wish  to  imply  that  there  is  one  well  defined  and 
universally  accepted  method  of  applying  mental  forces  as  a 
remedial  agent.  Doctors  of  all  descriptions  are  quite  univer- 
sally celebrated  for  their  differences  of  opinion,  and  mental 
healers  are  by  no  means  less  distinguished  in  this  respect  than 
those  who  rely  solely  upon  so-called  physical  measures.  For 
the  purpose  of  the  present  consideration  we  wish  simply  to 
recognize  the  fact  that  the  power  of  mind  to  dominate  mat- 
ter for  both  weal  and  woe  has  now  been  so  well  established  as 
to  deserve  universal  recognition  at  the  hands  of  the  medical 
profession,  and  to  outline  as  well  as  we  are  able  what  seems  to 
us,  for  the  present  at  least,  its  legitimate  field  of  application. 

All  phenomena  which  we  call  facts,  because  we  can  prove 
their  existence  by  sense  perception,  are  beyond  all  question 
simply  the  products  of  forces.  The  forces  themselves  we  can 
neither  hear,  see,  smell,  taste  nor  touch.  The  harmonious  opera- 
tion of  forces  which  we  call  health  is  by  no  means  a  naked  re- 
ality, but  appeals  to  our  consciousness  only  through  the  sym- 
metrical forms  which  it  takes  on.  The  discordant  operation  of 
indwelling  forces  which  alone  constitutes  disease  is  equally  hid- 
den from  sense  perception,  which  is  able  to  recognize  merely 
its  ill-shapen  results.  Both  health  and  disease  are  therefore  as 
incapable  of  diagnosis  by  physical  means  as  is  gravity,  elec- 
tricity and  every  other  power. 

Those  who  have  heretofore  fancied  that  they  could  de- 
tect the  presence  or  absence  of  either  health  or  disease  in  its 
incipiency  must  correct  their  impressions.  Only  by  their 
fruits  are  they  subject  to  our  ordinary  means  of  diagnosis. 

We  know  that  whatever  man  has  invented  or  constructed 
in  the  physical  world  has  been  accomplished  by  the  combined 
action  of  his  thoughts  and  feelings.  What  he  wanted  has  in- 


ORIFICIAL    SURGERY.  537 

variably  been  his  motive  power,  and  what  he  thought  has  un- 
der all  circumstances  furnished  it  shape.  The  heads  and  hearts 
have  thus  fathered  and  mothered  every  creation  of  man. 

Such  is  likewise  the  universal  plan  of  all  creation.  God's 
love,  clothed  with  his  wisdom,  has  brought  everything  that  is 
into  existence.  All  the  products  of  God's  creation  are  pro- 
nounced by  the  Creator  himself,  not  merely  in  his  written 
word  but  in  the  very  fact  that  he  created  them,  to  be  good. 
Both  his  love  and  his  wisdom  must  therefore  be  infinitely  good 
and  infinitely  true,  as  their  combined  operation  is  infinitely 
perfect. 

If  the  loves  and  the  thoughts  of  man  are  equally  respon- 
sible for  all  that  he  is  and  becomes  and  accomplishes,  and  if 
the  results  are  unsatisfactory,  the  real  fault  must  lie  with  what 
he  feels  or  what  he  thinks.  If  he  were  equally  pure-hearted 
and  clear-headed  with  the  God  who  made  him  and  sustains  him, 
all  his  works  would  be  correspondingly  perfect.  His  health 
would  be  perpetual  and  disease  would  be  unknown.  In  search- 
ing for  the  causes  of  disease,  therefore,  in  their  incipiency,  we 
must  inquire  into  his  affections  and  interrogate  his  mental  op- 
erations. In  both  God  and  man,  love  is  life,  and  truth  is  its 
form.  In  God  we  can  only  presume  that  his  love,  which  is  in- 
finite, is  pure  and  unselfish,  and  bestowed  in  all  its  fullness  up- 
on his  entire  creation.  He  must  love  it  for  its  own  sake,  and 
his  sole  source  of  satisfaction  must  be  in  giving.  His  infinite 
wisdom  must  be  co-equal  with  his  love  and  unerring  in  its  op- 
eration. With  him  there  can  be  no  sin,  sickness,  or  death.  In 
man,  love  may  be  of  two  kinds — a  love  of  God  and  man's  neigh- 
bor, or  a  love  of  self.  His  thoughts  can  be  true  and  logical,  or 
false  and  inconsistent.  Love  of  God  and  the  neighbor,  united 
with  true  thinking,  never  made  anybody  sick.  Such  a  result 
would  be  perfectly  incongruous  with  such  a  cause.  All  sick- 
ness, therefore,  must  result  from  some  form  of  selfishness  mar- 
ried to  some  type  of  falsity.  The  radical  cure  of  disease,  there- 
fore, involves  his  being  shorn  of  selfishness  and  established  in 
the  habits  of  correct  thinking.  And  is  this  not  the  true  scope 
of  mental  healing? 


538  ORIFIC1AL    SURGEKV. 

In  a  good  many  cases,  when  the  causes  of  disease  have 
been  removed,  the  disastrous  effects,  which  may  have  gone  no 
further  than  mere  functional  derangements,  will  speedily  dis- 
appear. And  in  such  eases  mental  therapeutics  should  furnish 
ample  remedial  measures.  At  other  times,  however,  where  dis- 
ease has  passed  the  boundary  lines  of  mere  functional  derange- 
ments, and  reached  the  stage  of  more  or  less  tangible  physical 
pathology,  the  establishment  of  correct  habits  of  thinking  and 
feeling  will  scarcely  be  able  to  undo  the  mischief  already  ac- 
complished until  the  time  comes  when  mental  forces  become 
sufficiently  powerful  to  raise  the  dead.  And  in  all  such  in- 
stances mental  healing  will  have  found  its  limitations,  and  will 
feel  the  need  of  so-called  physical  means  to  supplement  its  op- 
erations. Doctors  need  not  become  apprehensive  at  the  pros- 
pect of  the  inauguration  of  this  premeditated  attempt  to  eradi- 
cate disease  by  attacking  it  at  its  incipiency,  nor  let  their  scal- 
pels get  rusty,  nor  burn  up  their  splints  and  bandages,  nor 
empty  their  bottles,  for  some  little  time  to  come,  for  humanity 
has  erred  so  continuously  and  so  extensively  that  even  if  it 
should  become  universally  christianized  in  the  true  and  heal- 
ing sense  of  the  term,  the  particles  of  humanity  that  have  al- 
ready become  so  thoroughly  dead  as  to  be  beyond  resurrection, 
would  still  keep  the  so-called  physical  doctors  busy  for  a  long 
time  with  all  their  implements  for  molecular  grave  digging  in 
the  occupation  of  giving  the  various  products  of  destruction  a 
decent  burial.  The  present  scope  of  mental  healing,  it  seems 
to  us,  therefore,  is  the  eradication  from  the  human  heart  of 
selfishness  and  of  falsity,  and  its  present  limitations  we  would 
define  to  be  the  boundary  lines,  which  we  are  willing  to  con- 
fess are  more  or  less  indefinite,  between  functional  derange- 
ments and  organic  pathology.  Mental  and  physical  healers 
have  not  the  slightest  occasion,  therefore,  to  be  jealous  of  one 
another,  but  on  the  contrary  should  join  their  forces  in  a  com- 
bined attack  upon  sickness  and  death,  each  having  a  task  suf- 
ficiently arduous  to  satisfy  all  laudable  ambitions  for  work 
and  usefulness  in  the  interesting  pursuit  of  the  health  and 
happiness  and  longevity  of  the  human  race. 


ORIFIG1AL    SURGERY.  539 

If  mental  therapeutics  can  purify  the  wicked  hearts  and 
straighten  out  the  tangled  brains  of  men;  if  it  can  purge  hu- 
manity of  its  selfishness  and  inaugurate  correct  thinking,  no 
honorable  minded  practitioner  of  medicine  would  interfere 
with  its  labors,  but  on  the  contrary  bid  it  a  hearty  Godspeed 
and  aid  it  in  its  work  in  every  possible  manner.  The  only  ob- 
jection which  can  reasonably  be  raised  to  the  employment  of 
mental  therapeutics  is  the  ambition  of  too  optimistic  healers 
to  dispense  entirely  in  all  cases  of  disease  with  every  form  of 
physical  aid,  and  court  responsibilities  which  they  are,  as  yet 
at  least,  unfitted  to  bear,  and  which  are  sure,  therefore,  to  visit 
upon  their  heads  such  serious  sins  of  omission  and  commission 
as  to  bring  their  cause,  which  is  really  a  worthy  one  and  ca- 
pable of  much  good  if  prosecuted  with  a  safe  conservatism,  in- 
to well-earned  disrepute.  A  case  in  point  will  perhaps  fur- 
nish an  illustration  that  will  ensure  a  correct  interpretation  of 
our  position. 

A  man  of  much  worth  to  the  community  in  which  he  lived, 
and  between  fifty  and  sixty  years  of  age,  had  been  for  many 
years  suffering  from  severe  attacks  of  asthma,  accompanying 
a  chronic  bronchitis  which  he  had  long  kept  at  bay  by  re- 
peated vacations.  Being  of  a  skeptical  turn  of  mind  as  to  the 
efficiency  of  doctors,  in  his  case  at  least,  he  had  refused  their 
assistance  and  struggled  on  as  best  he  could  with  his  malady. 
His  good  wife  a  few  years  since  became  a  convert  to  what  is 
known  as  Christian  Science,  accepting  the  extreme  type  which 
denies  the  efficacy  in  disease  of  all  physical  remedies.  This 
little  family  was  an  illustration  of  the  homely  saying  that  "a 
prophet  is  not  without  honor  save  in  his  own  country."  The 
sick  man,  skeptical  concerning  doctors,  was  equally  skeptical 
concerning  the  doctrine  of  mental  healing,  so  that  the  frequent 
pleadings  of  his  wife  to  accept  her  extreme  views  on  mental 
therapeutics  were  steadily  resisted,  although  he  occasionally 
submitted  to  so-called  treatments,  and  as  he  often  thought 
with  benefit.  His  case  happened  to  be  one  of  a  type  in  which 
surgical  measures  are  uniformly  efficacious,  and  but  for  his 
skepticism  his  cure  at  any  time  could  have  been  easily  ef- 
fected by  the  aid  of  a  little  perfectly  safe  and  harmless  sur- 


540  ORIFIG1AL    SURGERY. 

gery.  But  while  his  fear  of  doctors  was  great  his  fear  of  sur- 
geons was  still  greater,  and  he  resolved  to  die  rather  than  sub- 
mit to  their  suggestions  and  procedures.  In  the  course  of  time 
his  malady  gradually  sapped  his  vitality  until  his  flesh  wasted 
to  an  extreme  degree,  his  heart  became  strained  and  diseased 
by  over-exertion,  dropsical  tendencies  began  to  manifest  them- 
selves in  his  feet  and  ankles,  and  his  breathing  was  so  labored 
that  he  was  unable  to  lie  down  or  sleep  more  than  an  hour  or 
two  in  the  twenty-four  even  in  a  sitting  posture;  when  his 
asthmatic  paroxysms  of  coughing  would  seize  him,  he  would 
grow  so  purple  in  the  face  that  it  seemed  to  his  watchers  that 
each  attack  would  end  the  struggle.  He  at  last  became  per- 
suaded that  his  end  was  near,  and  yet  he  was  not  willing  to 
die,  so  finally  surrendered.  It  was  to  a  doctor,  however,  and 
not  a  Christian  Scientist.  But  his  surrender  was  complete.  He 
mastered  his  worst  fears  and  summoned  a  surgeon.  The  case 
was  an  extreme  one,  having  been  neglected  so  long,  but  the 
surgeon  had  the  courage  of  his  convictions  and,  furnished  with 
ample  means  for  resuscitation,  placed  the  sufferer  under  an 
anesthetic  and  proceeded  with  the  operation,  which,  had  it 
been  accomplished  years  before,  would  have  undoubtedly  ef- 
fected a  speedy  cure  of  his  distressing  malady.  As  it  was  the 
patient  behaved  so  badly  under  the  anesthetic  that  only  a  part 
of  the  work  could  be  accomplished,  but  enough,  however,  to 
give  substantial  relief.  In  a  short  time  sleep  came  to  the  tired 
eyelids,  the  asthmatic  attacks  were  less  severe  and  frequent, 
the  appetite  returned,  the  heart's  action  became  stronger  and 
more  regular,  the  swelling  of  the  feet  disappeared,  and  the  pa- 
tient became  sufficiently  convalescent  to  visit  the  doctor  at  his 
office.  The  recovery  of  the  case  seemed  almost  like  a  resur- 
rection. 

But  now  comes  the  pitiful  part  of  the  history.  The  com- 
pletion of  the  surgical  work,  which  was  left  in  an  unfinished 
state,  was  deemed  necessary  by  the  surgeon  to  ensure  a  per- 
manency of  results.  The  patient,  however,  had  not  been  com- 
pletely cured  of  his  fear  of  the  surgeon's  knife,  and  as  the 
wife  again  put  in  her  plea  for  the  employment  of  mental  heal- 
ing in  the  case,  the  surgeon,  who  was  in  sympathy  with  the 


OEIFIC1AL    SURGEEY.  541 

employment  of  mental  therapeutics  when  practiced  with  proper 
limitations,  was  glad  to  accept  the  assistance  of  the  wife, 
through  whom  by  means  of  her  Christian  Science  accomplish- 
ments he  hoped  to  succeed  in  reassuring  his  patient  sufficiently 
to  be  permitted  to  complete  his  work  and  finish  the  cure  of 
the  case.  Imagine  his  disgust,  however,  when  the  patient,  who 
had  been  so  marvelously  rescued  by  physical  measures,  sur- 
rendered himself  completely  to  the  care  of  a  Christian  Scien- 
tist who  considered  it  her  first  duty  to  undermine  the  trustful 
confidence  of  the  patient  which  the  surgeon  had  honorably 
won.  She  demanded  that  he  should  rely  solely  upon  her  ef- 
forts and  completely  throw  aside  all  physical  crutches  of 
whatever  type.  She  was  not  willing  to  recognize  the  efficacy 
of  any  form  of  physical  measures  and  demanded  his  complete 
surrender  to  her  keeping.  The  responsibility,  great  as  it  was, 
was  placed  in  her  hands  and  the  surgeon  never  saw  his  dear 
friend  and  patient  again.  Inside  of  a  month's  time,  owing  un- 
questionably to  the  uncompleted  state  of  the  physical  work,  a 
relapse  ensued  and  the  metaphysician  proved  unworthy  the  tre- 
mendous responsibility  she  had  invited  and  accepted.  A  brief 
death  notice  in  a  morning  paper  told  the  interested  and  de- 
feated surgeon  that  while  one  poor  misguided,  unfortunate 
man,  a  valued  citizen  and  friend,  had  passed  to  his  grave  pre- 
maturely, there  was  still  living  a  woman  equally  poor,  unfortu- 
nate and  misguided,  who  had  already  done  much  mischief  by 
her  dangerous  fanaticism,  and  who  would  probably  do  still 
more  if  suitable  opportunities  presented  themselves  unless  re- 
morse for  her  uncalled-for  interference  and  its  disastrous  re- 
sults opened  her  eyes  to  the  error  of  her  ways,  a  consumma- 
tion devoutly  to  be  wished  for  but  scarcely  to  be  expected. 

There  is  one  thought  which  should  cure  extremists  of  the 
folly  of  fanaticism  in  the  direction  of  mental  healing,  and  that 
is  that  if  mind  is  God-made  so  is  matter,  or  what  we  call  matter, 
and  when  beneficial  effects  beyond  all  question  can  be  had  by 
material  agencies,  it  is  not  only  irrational,  but  in  responsible 
cases,  like  the  one  just  detailed,  positively  criminal  to  eschew 
their  help.  All  things  work  together  for  good,  and  mental 
therapeutics  and  all  the  physical  helps  of  the  doctor's  art  are 


542  ORIFIG1AL    SURGERY. 

by  no  means  incongruous,  but,  on  the  other  hand,  are  mutually 
helpful.  Those  who  give  their  exclusive  attention  to  the  study 
of  mental  healing  will  have  ample  opportunity  for  the  exercise 
of  all  their  powers  in  the  eradication  of  selfishness  and  ignor- 
ance from  mankind,  and  in  doing  so  they  will  undoubtedly 
make  many  cures  and  relieve  much  suffering.  For  that  task 
they  are  well  fitted,  and  in  that  labor  they  will  not  be  handi- 
capped or  interfered  with  by  any  doctor  who  has  the  good  of 
humanity  at  heart,  who  will  only  be  too  ready  to  join  their 
ranks  and  help  them. 

There  is  no  condition  of  health  or  disease  in  which  the 
element  of  fear  does  not  do  serious  mischief.  Let  suggestion 
be  aimed  at  it  until  every  vestige  of  it  is  destroyed.  There  is 
no  condition  of  health  or  disease  in  which  jealousy  is  not  harm- 
ful. Let  it  be  suggested  out  of  existence  by  all  means  as 
speedily  as  possible.  There  is  no  condition  of  health  or  disease 
to  which  greed  is  not  so  extremely  detrimental  that  it  deserves 
the  earnest  consideration  of  all  mental  healers.  It  is  a  com- 
mon as  well  as  grievous  fault.  There  is  no  condition  of  health 
or  disease  in  which  sensuality,  in  all  its  types,  is  not  only  dis- 
graceful but  also  disastrous.  Suggestive  therapeutics  is  es- 
pecially fitted  to  cope  with  it,  and  a  warfare  of  extermination 
should  be  at  once  inaugurated.  There  is  no  condition  of  health 
or  disease  in  which  hatred  is  not  a  dangerous  attribute.  Let  it 
be  marked  by  psychic  specialists  for  complete  extinction.  There 
is  no  condition  of  health  or  disease  that  worry  does  not  disturb 
and  damage.  Let  wholesome  thought  currents  be  directed 
against  it  until  it  is  annihilated.  Let  mental  healers  attack 
insincerity,  distrust,  infidelity,  skepticism,  and  ignorance,  and 
all  errors  of  the  heart  and  mistakes  of  the  head,  until  every 
thrill  of  selfishness  is  extracted  from  the  hearts,  and  every 
false  thought  or  suggestion  is  swept  from  the  brains  of  men. 
Disease  will  then  unquestionably  be  antidoted  at  its  source,  and 
although  all  its  effects  will  not  immediately  pass  away  punish- 
ment will  be  lessened,  and  the  physical  aid  furnished  mankind 
by  its  able  and  hard-working  corps  of  medical  experts  will  be 
more  rapid  in  its  action  and  permanent  in  its  effects.  In  the 
meantime  mental  healers  should  not  antagonize  the  medical 


ORIFJC'IAL    SURGERY.  543 

profession  by  courting  responsibilities  beyond  their  ability  to 
successfully  cope  with  and  foolishly  deny  the  efficacy  of  well- 
established  lines  of  cure,  which,  while  they  are  limited  in  their 
usefulness  to  be  sure,  are  still  invaluable  helps  to  humanity  in 
times  of  need.  "Let  all  things  work  together  for  good." 

CHAPTER  LXIX. 


SUGGESTIVE  THERAPEUTICS  IN  THE  TREATMENT  OF 

CHRONIC  CASES ;  OR  AS  AN  AID  TO 

ORIFICIAL  SURGERY. 


C.    T.    HOOD,    M.    D. 


At  the  request  of  your  secretary,  and  at  the  solicitation 
of  our  mutual  friend,  Professor  Pratt,  I  have  written  this  short 
paper  on  Suggestive  Therapeutics,  in  the  hope  that  perhaps  a 
few  ideas  might  be  presented  that  would  be  of  some  service 
to  you  in  the  treatment  of  chronic  diseases. 

It  is  not  intended  at  this  time  to  enter  into  any  scientific 
discussion,  or  present  any  scientific  basis  for  suggestive  thera- 
peutics. It  is  taken  for  granted  that  all  of  you,  or  at  least  all 
who  will  participate  in  the  discussion  of  this  paper,  admit  the 
so-called  hypnotic  state,  or  suggestive  state.  Nothing  will  be 
said  in  regard  to  the  induction  of  the  so-called  hypnotic  state, 
or  the  modus  operandi  necessary.  It  is  intended  in  this  paper 
simply  to  discuss  suggestion  in  its  relation  to  the  production 
and  relief  and  therapeutic  application  in  chronic  diseases. 

If  we  reiterate  some  things  that  are  familiar  to  you  all  in 
order  that  we  may  have  somewhat  of  a  practical  basis  upon 
which  to  begin  work,  the  only  excuse  we  offer  is  that  truth 
cannot  be  too  often  told. 

It  is  generally  admitted  today,  by  scientific  men  as  well  as 
neurologists,  that  the  human  mind  is  aduality ;  that  it  consists 
of  the  objective,  or  conscious,  mind,  and  the  subjective,  or  un- 
conscious, mind.  That  the  objective  mind  is  the  ego,  the  self, 
the  so-called  will  of  the  individual ;  that  it  presides  over  the 


544  ORIFiClAL   SURGERY. 

voluntary  acts  of  the  human  body;  that  being  the  will,  it  is 
like  all  other  parts  of  the  human  body  that  are  under  control 
of  the  will  or  the  voluntary  parts — it  requires  sleep  for  its  re- 
cuperation. The  objective  mind  has  a  certain  amount  of  con- 
trol over  the  subjective  mind,  but  it  only  exerts  this  control 
while  it,  the  objective  mind,  is  in  activity.  The  objective  mind, 
while  it  usually  acts  upon  reason,  in  very  many  instances  it 
acts  upon  suggestion.  The  more  enfeebled  the  will  or  the  ob- 
jective mind  is,  the  more  readily  will  it  accept  suggestions  and 
act  upon  them.  These  thoughts  are  of  importance  to  a  logical 
understanding  of  what  we  are  about  to  present. 

The  subjective  mind  is  of  a  very  different  character.  It 
presides  over  the  involuntary  parts  of  the  body;  its  action  is 
upon  digestion,  upon  absorption  and  assimilation,  and  excre- 
tion and  secretion ;  upon  the  circulation  of  the  blood ;  the  flow 
of  the  lymph ;  osmosis  and  endosmosis,  and  even  the  chemical 
action  that  takes  place  in  the  cells  is  to  a  certain  extent  under 
the  control  of  the  subjective  mind. 

The  subjective  mind  differs  also  from  the  objective  mind 
in  that  it  never  acts  upon  reason  or  by  reason,  but  always  acts 
by  suggestion  and  suggestion  alone.  The  odor  of  something 
cooking  produces  a  flow  of  saliva ;  the  sight  of  something  good 
to  eat  causes  the  saliva  to  flow ;  the  presence  of  food  in  the 
stomach  causes  gastric  juice  to  be  secreted. •  The  presence  of 
materials  in  the  intestinal  canal  causes  peristaltic  action.  The 
presence  of  blood  with  its  floating  material  in  the  kidney  caus- 
es the  excretion  and  secretion  of  urine.  And  so  through  the 
entire  apparently  complex,  yet  simple  process  of  normal  physi- 
ology. Yet  these  things  are  but  the  result  of  suggestions  con- 
veyed to  the  subjective  mind.  I  am  well  aware  that  this  is 
taking  rather  a  broad  stand,  but  I  do  not  at  this  time  care  to 
go  into  the  discussion  of  this  part  of  the  subject.  However, 
scientific  investigation  and  careful  experimenting  have  dem- 
onstrated— and  I  think  it  can  be  shown  to  any  candid  mind — 
that  these  are  facts.  Admitting  them,  we  have,  then  two 
propositions  for  discussion  in  accordance  with  our  subject. 

First.  What  part  does  suggestion  play  in  the  production 
of  chronic  diseased  conditions? 


ORIFIG1AL    SURGERY.  545 

Perhaps  we  had  better  leave  out  that  word  diseased,  and 
say,  What  part  has  suggestion  in  the  production  of  chronic 
conditions  ? 

First,  then,  what  part  does  the  objective  mind  take  in  the 
production  of  chronic  conditions? 

Keeping  in  mind  the  fact  that  the  objective  mind  usually 
acts  upon  reason,  but  that  it  frequently  accepts  suggestions,  it 
is  easy  to  understand  how  suggestions  to  the  objective  mind 
that  certain  parts  of  the  body  are  ill;  that  a  kidney  is  dis- 
eased ;  that  a  liver  is  diseased ;  that  digestion  is  abnormal ;  that 
nervous  prostration  is,  or  has,  come  with  all  its  train  of  symp- 
toms, and  the  objective  mind  by-and-by  accepts  the  suggestion 
that  there  is  a  diseased  condition.  It  accepts  this  suggestion 
to  such  an  extent  that  it  begins  by  degrees  to  impress  the  sug- 
gestion upon  the  subjective  mind.  The  subjective  mind,  acting 
upon  suggestion  and  suggestion  alone,  soon  accepts  the  fact  that 
digestion  is  disordered ;  that  the  activity  of  the  bowels  is  abnor- 
mal ;  that  pain  in  such  and  such  localities  actually  exists.  The 
result  is  a  chronic  condition  that  may  eventually  result  in  a 
true  pathological  condition,  because  the  subjective  mind  con- 
trolling the  circulation  of  the  blood  can  in  time  bring  about 
pathological  conditions.  Examples  of  these  conditions  are,  I 
am  sure,  familiar  to  you  all. 

Second.  What  part  does  the  subjective  mind  play  in  the 
production  of  chronic  conditions? 

Remembering  that  the  subjective  mind  acts  upon  sug- 
gestion and  suggestion  alone,  it  is  easy  to  understand  how 
peripheral  irritations  and  actual  pathological  conditions  can 
by  suggestion  bring  about  through  the  unconscious  or  sub- 
jective mind  chronic  conditions,  and  for  that  matter,  many 
acute  conditions.  Then  remembering  that  the  subjective  mind 
has  the  power,  while  the  objective  mind  is  asleep,  of  imprinting 
upon  the  objective  mind  suggestions  that  it,  the  subjective 
mind,  has  accepted,  so  that  in  time  the  objective  mind  accepts 
the  suggestion  given  it  by  the  subjective  mind  that  the  body 
is  diseased,  and  the  individual  himself,  by  his  own  reasoning, 
believes  that  he  is  sick.  These  being  facts,  which  I  think  you 
will  all  admit,  what  part  has  suggestion  in  the  treatment  of 


54«  OBIFIC1AL    SURGERY. 

chronic  conditions?  Or  how  can  it  be  of  assistance  to  the  ori- 
ficial  surgeon  in  the  treatment  of  this  large  class  of  cases! 

First,  through  the  objective  mind.  As  it  is  always  best 
to  individualize  our  cases  it  is  particularly  true  when  we  wish 
to  take  advantage  of  the  power  of  suggestion.  A  case  falls 
into  the  hands  of  a  physician,  and  the  question  is,  how  to  man- 
age it.  A  careful  study  of  the  case  will  determine  how  much  of 
the  diseased  condition,  or  perhaps,  better,  how  many  of  the 
symptoms  complained  of  are  the  result  of  suggestion  alone. 
If  the  physician  can  confidently  state  to  that  patient,  "Here  is 
the  seat  of  your  trouble ;  by  the  removal  of  this  difficulty  your 
recovery  is  assured  and  a  perfect  restoration  to  health  will  fol- 
low; if  he  can  convince  the  objective  mind  of  his  patient  that 
that  is  the  cause  and  that  its  removal  will  bring  health,  and  the 
objective  mind  of  the  patient  will  accept  that  suggestion  and 
imprint  it  upon  the  unconscious  mind  that  presides  over  the 
nutrition  of  the  body,  then  in  all  probability,  the  removal  of 
that  so-called  cause  will  result  in  a  restoration  to  health. 

If  on  the  other  hand,  there  are  peripheral  irritations  or 
actual  pathological  conditions  present  that  have  been  the  cause 
in  the  first  place  of  the  suggestions  that  have  resulted  in  the 
chronic  invalidism,  it  will  be  necessary  to  remove  those  local 
irritations.  Not  only  that,  but  the  objective  mind  as  well  must 
receive  the  suggestion,  not  only  from  the  subjective  mind,  but 
from  without,  and  be  convinced  that  health  will  result  before 
it  will  take  place.  This  is  why  failure  results  many  times  when 
excellent  work  has  been  done.  How  then  can  we  make  a  prac- 
tical application  of  these  facts  in  our  work? 

When  a  case  presents  itself  to  you,  be  very  emphatic  in 
what  you  can  do.  It  is  not  to  be,  "I  think  this  will  help  you," 
or  "I  believe  this  will  do  you  good,"  but  "I  know,  I  am  posi- 
tive that  this  will  do  what  I  say  it  will."  After  the  work  is 
done  many  times  the  results  are  not  all  that  you  expected ;  not 
all  that  your  patient  expected,  and  after-work  is  necessary; 
further  dilatation ;  further  douches ;  electricity ;  massage, 
Swedish  movement;  osteopathy,  and  even  Christian  Science. 
Yes,  I  am  sure  that  some  of  you  have  had  cases  in  which  all 
these  things  have  been  tried,  and  the  Materia  Medica  gone 


ORIFIGIAL    SURGERY.  547 

through  with  from  A  to  Z,  and  your  patient  still  not  well. 
Why  ?  Well,  I  can  tell  you  some  reasons : 

You  did  not  take  time  enough  in  the  preparation  of  that 
case.  You  should  have  treated  it  for  weeks  or  months.  If  it 
was  a  lacerated  cervix,  you  should  have  treated  it;  if  it  was  a 
diseased  rectum,  you  should  have  treated  it.  In  fact,  if  it  was 
any  condition,  you  should  have  taken  time  in  preparing  your 
patient.  You  forgot  that  the  objective  mind  had  accepted  the 
suggestion  of  disease,  and  you  did  not  sufficiently  eradicate 
that  suggestion  by  putting  in  the  suggestion  of  health ;  so  when 
normal  physiological  conditions  were  restored  as  perfectly  as 
possible,  the  objective  mind  still  clung  to  its  suggestion  of 
disease.  Then,  another  reason:  After  the  work  was  done  the 
suggestion  was  not  all  eradicated,  and  you  said,  "Well,  elec- 
tricity will  fix  you  all  right  now;  that's  all  you  need;  it  will 
cure  your  dyspepsia ;  it  will  make  you  sleep ;  it  will  make  you 
eat ;  it  will  make  your  bowels  act ;  in  fact,  it  will  finish  the 
thing  up,"  but  it  didn't.  Why?  If  you  think  that  you  can  eradi- 
cate a  whole  score  of  suggestions  that  have  found  lodgment  in 
the  human  mind  by  one  little  suggestion,  you  are  mistaken. 
But  had  you  suggested  to  that  patient,  "Electricity  will  help 
the  action  of  your  bowels,  it  will  help  you  to  sleep, ' '  and  stuck 
to  those  two  things,  it  would  have  accomplished  them.  And  so 
with  massage,  osteopathy,  Christian  Science  and  drugs.  Had 
you  picked  out  one,  or  at  most  two,  suggestions  to  be  removed 
by  the  new  thought,  the  object  would  have  been  accomplished. 

I  do  not  think  it  best  to  occupy  any  more  of  your  time  in 
the  presentation  of  this  subject. 

Now  after  the  paper  has  been  read,  I  am  sure  that  a  great 
many  of  you  are  saying  to  yourselves,  "Why,  that's  what  we 
do  every  day;  there  is  nothing  new  in  that:  that's  old."  Yes, 
we  realize  that ;  in  fact  there  is  nothing  new  under  the  sun, 
but  did  you  appreciate  it  when  you  did  it?  Did  you  do  it 
thoughtfully?  Did  you  intend  to  do  it?  Were  you  thinking 
about  it  when  you  did  it?  That's  the  point.  In  other  words, 
did  you  appreciate,  and  do  you  appreciate  what  part  sugges- 
tion plays  in  the  production  of  chronic  ailments?  If  we  have 
given  you  a  few  ideas,  or  presented  some  old  thoughts  in  a  lit- 


548  ORIFIG1AL    SURGERY. 

tie  different  dress  so  that  they  may  be  of  some  practical  serv- 
ice to  you,  our  time  has  been  well  spent.  But  in  the  future, 
watch  your  opportunity  and  study  the  power  of  suggestion. 
You  will  be  astonished,  as  I  have  been,  at  the  results  at- 
tainable. 

[The  first  thing  necessary  in  the  practical  application  of 
therapeutic  suggestion  is,  as  Dr.  Pratt  has  taught,  to  clean  up 
your  self — live,  breathe  and  BE  what  you  wish  to  photograph 
upon  the  subconscious  being  of  your  patient.  You  can't  wash 
soiled  spots  from  white  linen  with  dirty  water;  you  can't 
paint  a  house  white  with  drab  paint;  you  can't  show  a  bright 
light  through  a  greasy  smoked  globe.  You  must  take  the  beam 
out  of  your  own  eye,  then  you  can  see  clearly  to  remove  the 
mote  from  your  brother's  eye.  Not  an  easy  task.  However, 
we  can,  on  occasions  and  for  awhile,  attain  this  state  of  purity; 
by  strenuous  efforts  we  can  climb  to  this  high  terrace.  Even 
if  we  fall  back  the  effort  can  be  repeated,  for  the  view  and  tho 
glory  are  well  worth  while. 

The  best  time  is  when  your  patient  is  under  the  anesthetic. 
The  cerebro-spinal  man  is  asleep.  The  father,  boss  of  the  fam- 
ily, is  quieted — put  out  of  the  way  for  the  time  being.  Some 
men  are  so  noisy,  domineering  and  meddlesome  that  the  over- 
worked, timid,  tired,  sick  wife  has  no  opportunity  to  listen  to  or 
talk  with  another  while  he  is  present.  Now  with  this  pre- 
sumptuous lord  tucked  under  the  blanket  of  slumber,  we  can 
sit  down  and  in  a  quiet  but  forceful  heart-to-heart  talk,  give 
this  discouraged,  cringing  woman  some  wholesome  advice. 

In  operating  have  a  definite  purpose  in  your  mind :  not 
simply  to  do  good  bodily  repairing,  but  remember  you  are  at 
the  threshold  of  the  inner  sanctuary;  you  are  touching  the 
life-wires  of  the  soul;  you  are  fingering  the  strings  on  the 
sacred  harp  of  life;  you  are  on  holy  ground  and  your  shoes 
of  sensuality  and  impurity  must  be  removed.  Then  we  are 
ready  to  marry  mind  and  matter;  then  we  can  enter  the  foun- 
tains of  the  deep,  and  replace  hatred  with  love,  fear  with 
trust,  discouragement  with  hope,  jealousy  with  confidence, 
and  disease  with  health. — Editor.] 


SECTION  IX. 


Chronic  Diseases 

and 

Functional  Disturbances 


ORIFIC1AL    SURGERY. 


CHAPTER  LXX. 


LOWERED  VITALITY. 


H.    B.    BEEBE,    M.    D. 


What  means  this  term  and  how  it  is  to  be  overcome? 

The  life  and  vigor  of  an  organized  body  depends  upon  the 
physiological  functions,  the  aggregate  of  vital  actions,  the 
amount  of  tissue  resistance  of  that  organism. 

Lowered  vitality  is  simply  a  lack  or  loss  of  normal  tissue 
resistance.  When  the  physiology  of  an  organism  is  impaired 
we  have  pathology.  So-called  functional  diseases  cannot  long 
remain  without  resultant  structural  change  in  some  part  or 
parts  of  the  body.  The  diseased  anatomy  may  be  remote  from 
the  functional  manifestations.  Pathology  is  sick  physiology 
resulting  in  diseased  anatomy.  Pathological  processes  are  il- 
lustrations of  preverted  nutrition,  physiological  vital  action 
out  of  its  course,  all  embodied  in  the  term  lowered  vitality. 

The  sole  object  of  the  physician  and  surgeon  by  his  vari- 
ous modes  of  treatment  is  to  improve  nutrition,  re-establish 
healthy  physiological  functions,  elevate  vitality  and  correct 
morbid  anatomy,  that  the  normal  process  of  repair  and  waste 
may  go  on  undisturbed.  When  this  equilibrium  is  lost  some- 
thing is  wrong;  to  restore  it  is  to  cure  the  patient  whatever 
and  wherever  the  disease  may  be.  That  we  are  not  always 
able  to  do  this  none  will  deny,  and  as  to  how  it  is  done  when 
we  do  succeed  there  are  various  ways.  It  is  quite  well  settled 
that  Nature  is  the  successful  doctor  and  her  efforts  to  do  this 
work  are  great.  All  we  can  do  is  to  assist.  Her  powers  are 
not  inexhaustible  and  at  times  she  will  fail  when  but  little  aid 
is  needed.  This  is  more  true  in  chronic  diseases  where  she 
needs  special  assistance,  as  her  reparative  powers  are  more 
taxed  in  chronic  troubles. 

The  majority  of  acute  diseases  are  self-limited,  and  if  the 
reactive  powers  are  good,  recovery  is  to  be  expected  where 
ordinary  care  and  proper  therapeutic  means  are  used.  If  the 


552  OBlFIClAL   SURGEBY. 

life  force  the  vis  a  tergo  be  weak,  the  trouble  continues  till  we 
have  chronic  disease  affecting  the  weaker  parts  of  the  body. 

Of  the  many  measures  resorted  to  in  establishing  this 
lowered  vitality  to  a  normal  standard,  it  is  not  always  easy  to 
determine  which  is  best.  We  should  first  and  always  try  the 
simplest  and  mildest  conservative  methods.  Look  well  to  the 
hygiene,  regimen  and  sanitary  requirements  of  our  patient. 
If  these  measures  alone  will  cure,  well  and  good ;  if  not,  add  to 
these  resources  other  agents,  indicated  drug  remedies,  hydro- 
pathic applications,  electricity,  massage,  psychological  thera- 
peutics and  numerous  other  agents  well  known  to  the  skilled 
physician.  Any  of  these  measures  may  do  harm  when  not 
properly  applied.  Individualization  is  always  to  be  considered. 
Seldom  can  two  patients  be  treated  alike.  Conservative  means 
are  first  to  be  thought  of.  Let  surgery  be  used  only  as  a  der- 
nier resort.  When  it  is  necessary  be  not  slow  to  use  it. 

Many  of  the  valuable  agents  used  by  the  profession  in 
their  early  application  were  loudly  condemned,  until  their  true 
merits  were  established.  They  were  often  used  by  incompe- 
tent and  unprincipled  charlatans  to  the  injury  of  the  patient, 
as  well  as  that  of  the  worthy  advocate.  It  is  but  a  few  years 
since  that  that  very  potent  agent,  electricity,  so  valuable  a 
therapeutic  remedy,  was  considered  of  little  or  no  value  in  dis- 
ease, by  the  rank  and  file  of  our  profession.  All  of  these 
agents  have  their  proper  use  in  correcting  lowered  vitality, 
when  rightly  understood.  Quackery  has  injured  the  reputation 
of  valuable  measures  for  treating  diseases.  There  is  no  other 
opportunity  where  the  impostor  can  so  easily  dupe  his  vic- 
tims as  with  the  suffering  invalid.  Because  a  method  has  been 
badly  handled  it  must  not  be  discarded.  Remember:  "In  cer- 
tis  unitas ;  in  d\ibiis  libertas ;  in  omnibus  charitas. ' ' 

Twenty  years  ago,  the  late  Dr.  Beard  went  before  the 
British  Medical  Association  and  demonstrated  some  of  the  phe- 
nomena of  hypnotism.  He  was  insulted  and  practically  mob- 
bed by  Drs.  Crichton,  Brown,  Donkin  and  others  for  his  pains. 
At  the  recent  meeting  of  the  association  a  committee  appointed 
for  the  purpose,  reported  that  they  have  satisfied  themselves 


••>",'/  JiSU 

i  A     -:  r,     n  r. 


ORIFIG1AL   SURGERY.  553 

of  the  genuineness  of  the  phenomena  and  of  the  therapeutic 
value  of  the  method. 

The  same  may  be  said  of  another  method  lately  used  to 
arouse  lowered  vitality,  and  brought  before  a  similar  body  in 
1886,  the  oldest  national  medical  association  in  this  country. 
The  first  production  on  orificial  philosophy  presented  to  the 
American  Institute  at  Saratoga,  was  far  from  favorably  re- 
ceived. The  author,  too,  like  Dr.  Beard,  was  insulted  and 
practically  mobbed,  for  his  sincerity  in  advocating  views  of 
which  he  had  no  doubt.  A  self-constituted  committee  of  those 
present  was  there  appointed  to  investigate  the  merits  of  so  ab- 
surd a  doctrine.  In  this  case  it  did  not  take  ten  years  for  the 
committee  to  bring  in  a  similar  report  to  that  of  the  British 
Medical  Association,  as  the  late  meeting  at  Washington  cer- 
tainly proved.  The  difference  in  time  may  have  been  due  in  a 
measure,  to  the  way  in  which  the  Americans  do  things  when 
compared  with  our  British  brethren.  The  crank  who  pre- 
sented the  paper  six  years  before,  then  unsupported,  had  in- 
stead of  the  little  handful  of  disgusted  listeners,  a  large  audi- 
ence mostly  far  differently  impressed.  Many  of  them,  leaders 
in  the  profession,  had  tried  the  new  agent  and  were  only  too 
anxious  to  confirm  its  merits.  There  were  none  who  publicly 
opposed  it  as  at  the  first  meeting. 

It  has  become  a  well  established  fact  that  orificial  treat- 
ment will  arouse  sleepy,  dormant  life  force  to  a  normal  stand- 
ard after  other  well-known  agents  have  failed.  It  is  another 
potent  agent  in  the  physician's  armamentarium. 

The  successful  specialist,  the  author  of  the  new  measure, 
is  usually  dubbed  a  "crank,"  chiefly  because  he  advocates 
advanced  ideas  or  original  thoughts.  Some  one  has  said: 
' '  One  of  the  most  unfortunate  attributes  of  man  is  his  apparent 
unwillingness  to  be  unlike  other  men,"  his  seeming  dislike  of 
originality  so  far  as  he  himself  is  concerned,  and  his  sheep-like 
acquiescence  in  the  doing  of  others.  There  never  yet  was  what 
the  world  calls  a  crank  who  was  not  a  man  of  originality  of 
character,  of  intelligence,  a  man  who  was  literally  one  of  the 
cranks  that  are  instrumental  in  the  onward  movement  of  the 
world.  Julius  Caesar,  Napoleon,  George  Washington,  Carlyle, 


554  ORIFIG1AL    SURGERY. 

Bismarck,  were  all  cranks.  He  who  does  his  own  thinking  ana 
who  acts  for  himself,  based  upon  his  own  individuality,  is  what 
we  understand  the  word  "crank"  to  mean. 

The  orificialist  is  not  the  narrow-minded,  one-idea  person 
some  would  have  us  think.  To  meet  success  in  this  practice  is 
to  be  conservative,  to  carefully  individualize  the  cases,  to  look 
well  to  the  vis  medicatriv  naturoe.  Try  all  measures  to  assist 
Nature,  give  her  every  chance.  Do  not  treat  the  orifices  alone 
because  there  is  some  visible  local  trouble,  but  treat  the  pa- 
tient, the  vital  forces,  by  handling  the  great  organic  nervous 
system  by  way  of  the  orifices.  The  orificialist  is  a  neurologist, 
his  investigation  is  the  study  of  reflexes,  and  while  his  studies 
usually  refer  to  the  lower  orifices  of  the  body,  they  do  not  al- 
ways, for  there  are  reflexes  from  the  upper  orifices  demanding 
attention  at  the  same  time  we  are  treating  the  lower  openings 
of  the  body.  Of  the  eight  medical  colleges  announcing  pro- 
fessors of  orificial  surgery  in  their  catalogues,  several  of  them 
state  that  there  will  be  a  special  course  under  this  professor  on 
diseases  of  the  rectum.  They  do  not  seem  to  realize  that  while 
rectal  treatment  is  orificial  treatment,  orificial  treatment  is  far 
from  being  rectal  treatment  alone.  Said  announcement  might 
just  as  well  state  that  this  professor  will  give  a  special  course 
on  uterine  diseases  or  on  the  genito-urinary  organs.  This 
chair  is  not  filled  creditably  until  the  lecturer  treats  his  sub- 
ject from  the  standpoint  of  the  neurologist. 

But  some  orthodox  or  skeptical  doctor  asks:  "Why  not 
try  it  as  so  many  have  done  and  furnished  as  proof,  living, 
healthy  subjects  who  had  been  long  suffering  invalids?  Yes." 
he  says,  "but  I  have  seen  it  tried  and  it  did  not  do  iV."  Does 
anyone  say  that  there  are  not  cases  beyond  control  of  any  and 
all  means?  What  is  claimed  is  that  it  will  bring  reparative 
processes  in  many  cases,  often  where  everything  else  has  failed, 
if  the  treatment  be  skillfully  and  thoroughly  applied.  Because 
all  methods  fail  in  some  cases,  none  would  think  of  abandoning 
everything. 

The  work  of  the  true  orificialist  continues  after  that  of  the 
general  surgeon  ceases.  The  general  surgeon  treats  orificial 
diseases  for  their  local  manifestations.  The  orificialist  does  this 


ORIFIG1AL    SURGERY.  555 

and  also  in  addition,  by  his  work,  expects  to  arouse  the  low- 
ered vitality  to  a  healthy  physiological  standard,  and  thereby 
give  nature  a  better  chance  to  cure  the  patient.  The  average 
general  surgeon — he  who  does  major  surgical  work — dislikes 
orificial  work,  because  there  is  not  enough  cutting  with  it.  Its 
methods  are  entirely  too  mild,  simple  and  conservative.  Much 
of  the  treatment  is  not  surgery.  For  this  reason  I  have  never 
been  satisfied  with  the  term  orificial  surgery,  preferring  to  call 
it  orificial  methods.  Many  times  the  best  results  are  attained 
without  the  loss  of  blood.  It  is  certainly  very  appropriately 
termed  conservative  treatment.  We  believe,  in  fact  we  know, 
that  orificial  treatment  carried  to  completion  will  prevent  the 
necessity,  oftentimes,  of  major  surgical  work.  Give  it  a  thor- 
ough, impartial  trial,  you  who  have  not  already  done  so. 

CHAPTER  LXXI. 


FUNCTIONAL    DISTURBANCE    AND    MENTAL    CONDI- 
TIONS IN  CHRONIC  DISEASES. 


E.    P.   NOTREBE,   M.   D. 


The  simplest  forms  of  functional  disturbance,  such  as  in- 
digestion, constipation,  headaches,  fluttering  heart  are  but  the 
prodromes  of  the  more  serious  forms  of  the  so-called  diseases, 
such  as  chronic  skin  lesions  or  eczema,  dropsy,  asthma,  par- 
alysis, etc. ;  while  the  simple  forms  of  mental  disturbance,  as 
impatience,  dissatisfaction,  fear,  worry,  anger,  distrust  or  reck- 
lessness lead  to  the  symptoms  of  the  so-called  diseases  neu- 
rasthenia, insomnia,  epilepsy,  melancholia  insanity  and  imbe- 
cility. They  are  all  the  perversions  of  health  and  results  of 
disease. 

The  mental  symptoms  are  looked  upon  as  the  peculiarities 
of  an  individual  until  they  are  more  grave  then  they  are  re- 
garded as  sin.  We  have  been  taught  to  look  upon  sin  as  dis- 
graceful and  deserving  the  punishment  of  law,  but  taught  to 
excuse  disease  with  pity  and  to  encourage  it  to  weakness  and 


556  ORIFIC1AL   SURGERY. 

death,  with  gratification  of  every  childish  want.  We  should  be 
taught  to  be  ashamed  of  disease,  as  it  is  the  result  of  a  trans- 
gressed law  and  the  greatest  cause  of  sin.  Then  we  should 
be  charitable  with  the  symptoms  and  frailties  of  others  in  sin, 
for  they  are  crippled  and  weak  in  both  mind  and  body  and 
need  laws  of  body,  health  and  better  spiritual  thoughts  and 
feelings. 

The  human  body  is  simply  a  piece  of  machinery,  more 
perfect  than  any  that  has  ever  been  made.  In  treating  it  we 
should  look  upon  it  as  composed  of  individual  parts,  each  part 
having  a  special  work  to  do  and  each  part  deserving  a  certain 
amount  of  protection  and  respect.  When  we  fail  to  give  these 
parts  this  protection  and  respect,  we  will  have  in  this  ma- 
chinery a  disturbance  in  action  and  work  and  a  detrimental 
change  in  its  products  and  their  uses. 

In  a  successful  manufacturing  plant  we  will  have  special 
parts  and  individuals  given  special  attention  and  respect.  We 
will  have  a  chief  engineer  to  supervise  the  whole  machinery 
and  see  that  a  good  machinist  keeps  the  bands  and  wheels 
properly  connected  and  in  good  running  order.  We  will  have 
a  carpenter  to  see  that  the  building  is  protected  and  repaired 
with  proper  material;  we  will  have  good,  earnest  and  faith- 
ful laborers  to  handle  the  material,  carry  away  the  waste  and 
store  away  the  products,  and  these  specialized  if  the  work  de- 
mands. 

We  will  also  have  a  man  of  principle,  a  man  of  action,  a 
man  of  brain,  a  man  of  feeling,  as  general  manager  of  this 
business.  This  man  should  see  that  his  chief  engineer  is  pro- 
vided for,  that  he  attends  to  his  duties  and  is  protected,  in  or- 
der that  he  may  not  become  weak,  diseased  and  negligent,  al- 
lowing the  machinery  to  become  irregular  in  action  and  dis- 
connected and  run  to  extremes,  nervousness,  an  explosion,  par- 
alysis and  death. 

The  laborers  should  be  guided,  favored  and  protected  in 
order  that  their  energies  should  equal  the  capacity.  If  these 
elements  are  kept  in  harmony  the  then  manufactured  products 
will  be  good  in  quality  and  sufficient  in  quantity  to  please  and 
bring  a  smile  and  ease  of  action  to  the  general  manager  so 


OKIFIG1AL    SUBGERY.  557 

that  he  can  turn  over  a  surplus  to  the  owners  that  will  please 
and  bring  a  smile  and  ease  to  their  souls,  that  will  return  a 
good  support  and  continuance  to  the  business. 

We  would  call  this  a  beautiful  work,  something  worthy  of 
attention  and  interest.  In  the  human  body  we  can  have  this 
condition  or  we  can  have  explosion,  paralysis,  and  death. 

In  our  search  for  and  preservation  of  health  we  should 
give  every  tissue  in  the  body  the  responsibility,  protection  and 
respect  of  a  specialist,  these  specialists  having  in  common  one 
end — the  production  of  the  elements  necessary  to  health.  The 
nerves  are  made  up  of  special  cells  whose  properties  are  sen- 
sitiveness and  action.  The  special  cells  of  contractility  make 
muscle  tissue.  The  special  sells  of  secretion  make  the  secre- 
tory system.  The  special  cells  of  reproduction  make  the  repro- 
ductive apparatus.  The  bony  cells  make  the  bone  tissue  for 
the  support  of  the  body,  etc. 

All  of  these  may  be  managed,  supported  and  protected  in 
order  that  they  can  attend  to  their  duties. 

In  the  nervous  systems  we  have  as  the  chief  engineer  the 
abdominal  brain,  and  his  machinist,  the  cervical,  hypogastric 
and  other  plexuses;  the  general  manager  is  the  brain  and 
spinal  cord. 

The  important  laborers  of  the  body  machine  are  under  the 
control  mainly  of  the  chief  engineer  or  the  sympathetic  ner- 
vous system,  and  comprise  the  heart,  lungs,  stomach,  liver,  kid- 
neys, intestinal  tract  and  all  other  functional  organs  of  the 
body.  These  parts  or  laborers  must  take  in,  prepare  and  give 
food  products  to  the  tissues  and  dispose  of  the  waste.  It  is 
among  the  laborers  that  we  usually  find  troubles  that  cause 
disturbance  throughout  the  plant  or  body  and  we  should  give 
them  attention,  for  when  the  laborers  become  weak  the  source 
of  revenue  becomes  disturbed  and  sometimes  so  embarrassed 
that  there  is  a  failure. 

We  as  physicians  should  be  good  machinists,  good  car- 
penters and  good  general  managers  and  should  have  and  use 
the  privilege  of  closely  examining  the  body  from  head  to  foot 
and  should  know  what  nerves  control  organs  and  from  where 
an  organ  gets  its  commands  and  how  much  it  should  work  and 


558  OBIFIC1AL    SURGERY. 

how  much  it  should  rest.  Then  we  will  probably  be  able  to 
tell  a  patient  more  of  his  condition  than  he  himself  knows  and 
be  of  some  benefit  to  him. 

Nervous  cases  have  many  symptoms  in  common,  such  as 
indigestion,  constipation,  headache,  liver,  kidney,  bladder, 
heart,  lung,  throat  and  skin  troubles,  and  in  fact  all  degrees  of 
disturbances  of  the  functions  of  the  vital  organs.  They  can 
find  their  cases  exactly  depicted  in  any  newspaper  almanac  or 
descriptive  book  of  diseases.  This  means  something,  and  these 
invalids  are  not  very  much  mistaken,  and  we  should  stop  to 
find  the  cause  of  all  these  troubles,  for  we  can  detect  symptoms 
ad  infinitum  and  to  deal  with  them  is  like  picking  the  leaves 
off  a  tree  to  kill  it.  Let  us  use  the  same  common  sense  in  de- 
tecting and  adjusting  the  friction  of  the  body  that  we  would 
in  a  manufacturing  plant  or  business.  In  that  business  we 
would  first  go  to  the  two  main  heads,  the  general  manager  and 
the  chief  engineer,  to  determine  what  is  wrong  for  all  com- 
mands should  originate  with  them. 

Is  your  general  manager  on  a  drunk  ?  If  so,  their  will  be 
immediate  trouble  unless  the  engineer  is  sober  and  at  his  post. 
Is  the  engineer  disturbed?  If  so,  there  is  immediate  danger. 
Unless  these  two  commanders  are  right,  the  business  is  in  dan- 
ger, and  if  one  is  continually  wrong  the  house  must  fall,  or 
from  bad  commands  we  will  have  bad  work  from  the  laborers 
and  hence  bad  results.  The  sympathetic  nervous  system  is  the 
great  commander  through  its  centers  (namely:  the  solar,  cer- 
vical and  hypogastric  plexuses)  of  all  the  vital  organs;  and 
the  reason  that  chronic  cases  have  disturbance  of  the  func- 
tions of  all  these  organs  is  that  the  centers  that  send  cords  to 
those  organs  and  control  their  action  entirely  by  commands 
are  disturbed,  and  it  is  natural,  since  there  is  no  shut-off  from 
those  centers  that  every  organ  should  be  aroused  when  the 
centers  are  irritated.  Then  when  the  sympathetic  nerve  cen- 
ters are  irritated  there  will  be  an  irritation  of  every  vital  or- 
gan in  the  body  and  a  consequent  disturbance  in  its  action  and 
it  will  only  be  a  question  of  endurance  as  to  which  organ  will 
become  tired,  weak  or  diseased  first:  and  the  one  that  shows 


ORIFIC1AL    SURGERY.  559 

this  influence  the  most  is  the  organ  that  the  patient  usually 
thinks  is  diseased. 

The  solar  plexus  or  abdominal  brain  when  disturbed  rings 
up  "Mr.  Heart"  and  tells  him  to  get  on  extra  duty.  It  says 
the  same  to  lungs,  liver,  kidneys,  stomach,  bowels  or  secretory 
and  circulatory  cells  throughout  the  body.  They  all  do  extra 
duty,  but  like  many  other  individuals  with  individual  rights, 
after  a  time  extra  duty  becomes  tiresome  and,  like  individuals 
still,  if  they  get  no  rest  they  become  impatient;  and  still  if 
no  rest  comes  they  become  dissatisfied  with  their  master;  and 
still  if  no  rest  they  become  disgruntled  and  irritable,  and  then 
after  pleading,  if  there  is  no  rest,  there  will  be  a  struggle,  an 
explosion,  disease  and  death. 

Vital  organs  and  tissues  are.  simply  individual  laborers 
making  up  the  whole  body,  its  products  and  expressions,  and 
as  these  vital  organs  or  tissues  act  so  the  man  will  act.  Instead 
of  the  surface  man  being  responsible  he  is  simply  the  product 
of  inner  forces.  A  weak  muscular  man  means  that  the  mus- 
cles are  not  properly  fed  and  cared  for.  A  weak  bony  man 
means  that  the  bony  individual  is  neglected.  A  weak  mucous 
membrane  man  means  that  his  tissue  is  starved  and  neglected. 
A  weak  skin  man  means  that  there  is  starvation  in  his  house 
and  a  weak  nervous  man  means  that  there  is  starvation  and 
neglect  there,  too.  When  the  weak  muscular  man  is  despondent 
and  wishes  something  done  we  encourage  him  immediately  and 
say,  "Why,  you  just  need  food  and  all  will  be  well  soon." 
Food  is  the  essential  for  health  and  happiness  to  nervous 
tissue,  to  mucous  membrane  tissue,  to  skin  tissue  and  to  bony 
tissue  and  to  all  tissues  alike  and  they  also  will  improve  by 
its  supply ;  then  in  order  to  cure  chronic  conditions  of  mucous 
membrane,  as  catarrh,  in  order  to  cure  chronic  conditions  of 
skin  and  nerves  why  not  pursue  the  same  common  sense  course 
and  expect  the  same  results  as  we  would  in  muscular  weak- 
ness, for  these  tissues  are  subject  to  the  same  laws  of  life  and 
healthy  action  ?  We  must  see  to  the  food  supply  in  order  to 
have  health  and  all  that  goes  with  it. 

The  sympathetic  nervous  centers  command  all  the  food 
preparers  and  carriers  of  the  tissues ;  they  send  cords  that  con- 


560  OBIFIG1AL   SURGERY. 

nect  with  gland  cells  or  agents  in  the  stomach  that  control  di- 
gestion there;  they  send  cords  that  connect  with  gland  cells 
in  the  bowels  that  control  digestion  and  excretion  there ;  they 
send  cords  that  connect  with  gland  cells  or  agents  in  the  liver 
that  control  its  labor;  they  send  cords  that  connect  with  cells 
or  age'nts  in  the  kidneys  and  control  their  work;  they  send 
cords  that  connect  with  cells  or  agents  in  the  heart  that  give  it 
force  to  carry  food;  they  send  cords  that  connect  with  agents 
in  the  lungs  that  control  the  fuel  of  the  machinery.  If  this 
system  is  disturbed  it  will  then  cause  irregularity  and  weak- 
ness of  stomach  and  bowel  digestion,  or  indigestion,  disturb- 
ance of  liver,  kidneys,  skin,  lungs  and  the  heart  and  blood  ves- 
sels, the  railroad  system  or  carriers  of  the  food. 

Tissues  are  just  like  we  are:  Let  the  laborer  be  deficient 
in  making  food  products,  then  add  to  that  a  disturbance  in  the 
railroad  system  that  will  not  carry  what  we  might  have,  and 
imagine  our  actions ;  and  stand  the  nervous  system  by  our  side 
under  similar  conditions  and  see  its  actions.  First,  we  would 
both  see  that  food  supply  was  getting  scarce;  next  we  would 
think  that  the  railroads  were  irregular  in  running,  and  we 
might  not  get  just  what  we  needed  at  the  right  time.  This 
knowledge  would  arouse  interest,  we  would  become  a  little 
anxious,  and  begin  to  accelerate  our  efforts  to  lay  up,  but  if 
with  the  acceleration  we  still  gained  nothing,  but  were  losing, 
we  would  become  restless  and  overworked  and  tired,  then 
we  would  begin  to  draw  on  what  we  had  reserved,  and  if  we 
did  not  have  enough  we  would  call  on  some  one  else.  If  we 
failed  we  would  become  weak,  grow  impatient,  distrustful  and 
irritable,  and  would  worry  and  lose  sleep,  and  at  last  become 
desperate.  The  tension  would  be  so  great  that  there  would 
be  an  explosion  and  we  would  go  mad,  or  else  the  weakness 
would  be  so  great  that  paralysis  or  death  would  ensue. 

Remove  the  cause  of  disturbance  of  food  laborers,  make 
food,  and  feed  this  man,  and  he  will  gradually  recover  from 
that  wild  state  to  a  sane,  stout  man.  Remove  the  cause  of  ir- 
ritation to  the  nerve  food  laborers,  turn  them  loose  and  feed 
the  nerve,  and  that  insane,  weak  nerve  will  become  strong  and 
calm  again. 


OEIFICTAL    SURGERY.  561 

The  peculiarity  of  a  weak  thing  is  its  susceptibility  of 
being  moved  or  impressed,  and  a  weak  person  is  a  nervous  per- 
son, for  weakness  makes  the  nerves  susceptible  to  action,  and 
their  thoughts  are  numerous;  they  want  to  talk  a  great  deal, 
they  see  things  quickly ;  and,  while  weakness  is  a  hindrance  to 
most  forces,  it  acts  as  an  accelerator  to  thought  forces,  for 
thought  is  simply  the  result  of  irritation  of  brain  cells  arousing 
them  to  action.  You  never  thought  of  a  man  unless  you  saw 
him,  heard  of  him,  or  by  some  of  the  senses  had  an  irritation 
of  him.  It  does  not  rob  God  nor  interfere  with  his  divine  prin- 
ciples for  us  to  know  thought  laws  any  more  than  to  know  the 
laws  of  gravitation.  This  knowledge  should  make  us  more 
grateful,  more  trustful,  more  hopeful,  and  more  confiding  in 
such  a  Creator  —  a  Creator  who  has  given  us  individuality, 
a  Creator  who  has  given  us  force,  a  Creator  who  has  given 
us  such  sensitive  means  to  thoughts  and  feelings,  and  has  given 
us  a  crowning  purpose  for  which  the  right  use  of  thought  laws 
was  intended.  Our  discovery  and  understanding  of  orificial 
laws  should  not  cause  us  to  rob  and  depreciate  its  founder, 
E.  H.  Pratt.  He  owes  us  nothing,  but  we  owe  it  all  to  him, 
more  than  money  can  pay.  But  he  has  given  us  an  insight  to 
better  principles  of  thought  and  feeling,  and  through  their 
coin  he  can  be  rewarded.  Thought  forces,  like  all  other  forces, 
can  be  used  for  destruction  as  well  as  construction,  are  sub- 
ject to  bad  as  well  as  good  impressions,  and  should  be 
handled  with  care. 

To  illustrate  the  breaking  down  of  special  tissues  I  report 
the  following  cases: 

Case  1.  Most  prominent  symptoms:  insanity  and  emaci- 
ation. Unmarried  woman  30  years  old,  family  history  good. 
She  had  been  treated  for  ten  to  twelve  years  for  chronic  indi- 
gestion, constipation  and  nervousness.  Her  insanity  dates 
back  about  three  to  five  years.  Did  not  care  for  detailed  his- 
tory of  the  case,  thinking  it  would  not  give  the  cause,  as  par- 
ents usually  attribute  such  troubles  to  a  fall,  fright,  taking 
cold  or  something  of  the  kind  which  has  very  little  to  do  with 
the  real  cause.  By  symptomatic  examination  could  see  every 
organ  in  her  body  was  weak ;  weight  about  65  pounds,  when 


562  ORIFIG1AL   SURGERY. 

she  should  have  weighed  120  to  130.  Examination  of  body  re- 
vealed clitoris  completely  covered  and  hood  adherent;  hymen 
and  vagina  in  chronic  granular,  ulcerated  condition;  mouth 
and  neck  of  uterus  eroded,  soft  and  friable  with  granula- 
tions; chronic  endometritis  and  uterus  without  tone.  Rectum 
full  of  ulcerated  pockets  and  papillae  and  in  a  state  of  granular 
degeneration.  Lower  bowel  was  so  dead  and  dry  that  fecal 
lumps  adhered  to  the  walls  as  though  baked.  All  her  mucous 
membranes  were  in  a  catarrhal  condition.  Like  all  such  cases 
she  was  intense  in  her  desires  and  suspicions.  She  had  only 
one  or  two  thoughts  and  used  them  incessantly  day  and  night. 
She  was  as  troublesome  as  a  case  of  this  kind  could  be. 

Operation  consisted  in  freeing  the  clitoris;  clipping,  trim- 
ming and  curetting  hymen  and  vagina ;  dilating,  curetting  and 
amputating  neck  of  uterus;  slit  operation  on  rectum  after  in- 
troducing wool  plug  saturated  with  balsam  of  Peru  and  Pond's 
extract,  which  was  left  in  for  four  days.  She  was  so  uncontrol- 
lable that  it  was  necessary  to  chloroform  her  to  keep  her 
quiet  and  treat  her  for  two  or  three  weeks,  as  morphia,  sul- 
fonal,  chloral,  etc.,  had  no  effect.  She  did  not  seem  to  change 
until  the  third  week  when  she  had  two  or  three  hard  chills  and 
fever,  which  was  caused  by  the  secretions  being  aroused;  tem- 
perature ran  up  to  105.  After  the  fever  abated  she  began  to 
notice,  you  could  attract  her  attention  and  she  would  obey. 
About  this  time  she  complained  of  pain  in  the  limbs  and  head 
and  would  grunt  when  she  seemed  to  suffer.  Up  to  this  time 
there  had  been  no  expression  of  what  would  usually  give  pain 
to  any  one.  This  is  a  common  condition  of  insane  cases.  In 
her  case  the  brain  gave  way  before  any  of  the  other  organs, 
from  starvation,  and  she  became  insane.  It  might  as  well  have 
been  her  lungs  causing  consumption  or  her  kidneys  or  heart  or 
liver  causing  dropsy.  It  is  now  five  weeks  since  she  left  the 
sanitarium  and  she  comes  in  twice  a  week  for  treatment.  She 
is  gaming  rapidly  in  flesh,  and  while  she  has,  of  course,  nerv- 
ous thoughts  and  wants,  she  is  rational  and  takes  care  of  her- 
self without  being  watched.  All  the  abnormal  conditions  of 
her  nervous  system  must  be  eliminated  by  time,  strength  and 
growth,  and  her  mind  become  healthy. 


ORIFIC1AL    SURGERY.  563 

Case  2.  Prominent  symptom,  dropsy.  Heart,  lungs,  kid- 
neys and  liver  all  appeared  to  be  so  disturbed  that  it  seemed 
they  must  be  broken  down  in  tissue.  Considered  the  case  en- 
tirely hopeless;  in  fact  regretted  her  coming  to  me  for  treat- 
ment. After  explaining  to  her  her  condition  she  was  willing 
to  take  the  one  chance,  though  it  seemed  small.  There  was  so 
much  heart  and  lung  trouble  that  she  had  not  been  able  to  lie 
down  for  weeks  and  only  slept  one  to  two  hours  in  twenty- 
four,  and  that  was  broken  rest,  as  she  had  an  almost  incessant 
cough. 

On  examination  I  found  Skene's  glands  enlarged  until 
some  were  1%  to  2  inches  deep  and  the  tissue  all  around  the 
meatus  was  so  hyperplastic  that  it  seemed  cicatricial.  The 
cervix  had  a  bilateral  laceration  and  the  rectum  was  studded 
with  piles,  pockets  and  papillae. 

I  knew  she  could  stand  no  operation  in  her  present  con- 
dition, so  began  preparatory  treatment  by  rectal  dilatation  and 
heart  stimulants,  strophanthus  and  cactina.  In  about  ten  days 
I  considered  her  circulation  much  improved  and  removed  by 
tapping  about  three  gallons  of  serum,  repeated  the  tapping 
twice,  removing  in  all  seven  gallons.  In  two  weeks  from  time 
she  came  to  the  sanitarium  I  removed  piles,  pockets  and  papil- 
lae, cut  out  Skene's  glands  and  hyperplastic  tissue.  Operation 
lasted  one  hour  and  a  half.  Patient  has  been  in  comparative 
ease  since,  sleeps  all  night,  lies  on  her  back  comfortably.  Ex- 
pect to  repair  lacerated  cervix  in  a  short  time. 

Wishing  to  give  credit  where  it  is  due  I  will  say  I  was 
much  encouraged  by  the  assistance  of  Dr.  Warden,  whose 
thorough  confidence  in  and  knowledge  of  the  work  relieved  me 
from  all  anxiety  in  the  management  of  the  anesthetic.  But  for 
this  and  my  knowledge  of  the  effect  on  heart  and  lungs  of  rec- 
tal dilatation  I  would  no  more  have  put  that  woman  on  the 
operating  table  than  I  would  have  shot  her. 

Case  3.  Invalid,  asthma  for  five  years.  Had  been  wheeled 
in  invalid's  chair  and  carried  in  husband's  arms  for  five  years; 
was  thought  to  be  in  last  stages  of  consumption,  life  wretched 
and  hope  about  gone.  All  that  was  left  of  her  was  a  small 
bundle  of  extreme,  petulant,  sickly  wants.  She  had  been  a 


564  ORIFIG1AL    SURGERY. 

belle  in  looks  and  merriment,  but,  oh,  what  a  change!  She 
was  so  distorted  that  one  could  not  begin  to  please.  Even  her 
husband,  who  was  as  loyal  and  attentive  as  the  name  can  im- 
ply, could  not  satisfy  her  in  the  smallest  particular.  If  he 
handed  her  a  glass  of  water  it  was  too  little,  too  much,  too  hot, 
too  cold,  or  he  did  not  come  quickly  enough  or  was  too 
quick,  etc. 

Examination  showed  the  lungs  and  heart  weak  and  dis- 
turbed in  action,  but  not  diseased  in  tissue  any  more  than  the 
irritation  of  bronchial  tubes  in  asthma.  Clitoris  completely 
covered  and  hood  adherent;  meatus  fiery  red,  with  irritation; 
Skene's  glands  enlarged,  numerous  and  loaded  with  pus;  bi- 
lateral laceration  of  cervix  and  chronic  endometritis.  Rectum 
pinched  and  last  inch  badly  diseased  with  hemorrhoids,  pock- 
ets and  papillae. 

Did  all-around  work  as  indicated,  and  in  twenty-four 
hours  asthma  relaxed  and  she  had  no  more  attacks  for  about 
six  days,  when  the  rectum  began  to  pinch  and  she  suffered  all 
night  with  asthma.  I  asked  her  why  she  did  not  have  me 
called,  and  she  said  she  did  not  think  I  could  do  anything  for 
the  asthma.  I  dilated  the  rectum,  and  in  a  few  minutes  she 
was  relieved.  But  she  still  clung  to  her  asthma  inhaler  that 
had  been  by  her  bedside  for  years  and  it  was  months  before  she 
would  leave  it  at  home.  In  three  weeks  she  was  up  and  began 
to  walk,  and  in  five  weeks  could  enjoy  a  lively  buggy  ride.  She 
then  went  home  and  had  a  slight  return  of  asthma  with  other 
complaints,  and  I  had  her  come  back.  The  rectum  seemed  in 
good  condition,  the  uterus  was  much  improved  and  I  could  not 
understand  why  she  had  asthma.  Was  treating  her  with  elec- 
tricity, and  noticed  that  the  meatus  was  still  irritated ;  applied 
the  negative  galvanic  current  and  that  night  she  had  a  very 
severe  attack  of  asthma.  As  this  irritation  was  removed  she 
became  better  and  better  until  the  asthma  is  about  forgotten, 
together  with  other  morbid  symptoms,  and  she  is  getting  back 
her  former  good  qualities  and  there  is  happiness  in  that  home. 

Case  4.  Most  prominent  symptoms,  skin  lesion  and  dropsy. 
A  young  lady  fourteen  years  old.  She  had  an  eruption  over 
the  entire  body,  and  lower  limbs  were  in  a  chronic  condition 


ORtFIGlAL    SURGERY.  565 

of  ulceration  from  three  inches  above  knees  to  feet,  and  had 
been  so  for  several  years.  She  had  been  treated  for  varicose 
ulcers  of  legs  for  nine  years.  The  rest  of  the  body  was  patched 
with  pimples  and  old  sores.  Her  feet  and  limbs  were  much 
swollen,  she  was  troubled  with  incessant  itching,  and  could 
not  sleep  more  than  two  or  three  hours  in  twenty-four. 

Physicians  had  told  parents  that  nothing  could  be  done, 
and  when  they  spoke  of  having  her  operated  on  they  said  it 
would  be  brutal  to  think  of  giving  her  an  anesthetic ;  it  would 
kill  her  instantly,  but  she  could  not  be  cured  with  medicines, 
as  she  had  been  under  constant  treatment  for  nine  years,  was 
rapidly  growing  worse  and  it  seemed  she  could  not  live  long. 
The  parents  thought  it  was  death  anyway  and  decided  on  an 
operation. 

Examination  revealed  clitoris  completely  covered  and  rec- 
tum studded  with  pockets  and  papillae.  Four  days  after  clip- 
ping the  hood  and  freeing  the  clitoris  and  doing  the  slit  opera- 
tion the  pimples  and  sores  began  to  disappear.  In  three  weeks 
after  operation  her  whole  body  was  perfectly  smooth  with  the 
exception  of  a  few  pimples  on  her  face;  the  varicose  ulcers  on 
legs  were  completely  well.  She  went  home  and  her  physician 
said  the  eruption  just  happened  to  get  better — I  had  done 
nothing. 

In  four  months  her  first  menstrual  period  appeared  and 
immediately  the  eruption  re-appeared,  though  not  severe.  I 
had  paid  no  attention  to  vagina  and  uterus,  thinking  she  was 
young  and  would  have  no  trouble  there,  but  my  work  was  not 
complete.  I  had  not  removed  all  irritation.  I  am  surprised  at 
her  improvement,  for  on  closer  examination  found  the  hymen 
very  irritable,  uterus  retroverted  and  endometrium  very  much 
inflamed.  After  removal  of  these  conditions  by  operation  and 
after-treatment  with  electricity,  the  young  lady  is  well,  has  a 
beautiful  complexion,  has  grown  much  and  gained  forty 
pounds  in  one  year. 


566  ORIFIC1AL    SURGERY. 


CHAPTER  LXXII. 


INSOMNIA;  ITS  RELIEF  BY  ORIFICIAL  METHODS. 


I*  C.  GROSVENOR.  M.  D. 


Case  1.  A  college  graduate  pursuing  an  advanced  course 
of  study  across  the  water  became  gradually  the  victim  of  in- 
somnia. 

Bright,  ambitious,  and  hopeful  in  his  efforts  to  better  pre- 
pare himself  for  a  college  chair  of  Modern  Languages,  he  felt 
this  handicap  keenly.  As  I  had  been  his  medical  friend  during 
his  college  course,  he  naturally  turned  to  me  for  advice. 

At  my  suggestion  he  came  home  for  treatment,  as  the  dis- 
tinguished surgeon  across  the  water  had  not  yet  learned  the 
new  philosophy.  He  was  placed  in  the  Lincoln  Park  Sani- 
tarium, where  dilatation  of  the  lower  orifices,  circumcision  and 
thorough  rectal  work  were  done. 

In  four  weeks  he  recrossed  the  ocean,  completed  his 
course  of  study,  and  has  for  one  year  filled  an  important  po- 
sition in  an  educational  institution.  Not  only  was  his  sleepless- 
ness completely  cured,  but  he  claims  that  his  mental  grasp  and 
power  of  continued  thought  are  greatly  improved.  His  friends, 
too,  notice  his  cool,  quiet,  self-contained  manner  with  its  sug- 
gestions of  reserved  power  in  place  of  the  former  nervous 
unrest. 

Case  2.  An  old  gentleman  who  could  not  sleep  after  2 
o'clock  in  the  morning  was  much  improved  by  rectal  work 
and  the  occasional  use  of  the  rectal  plug. 

Case  3.  A  little  boy  in  one  of  our  best  families  suffered 
from  insomnia  and  made  night  a  terror  to  his  family. 

He  was  thin,  spare,  capricious  in  appetite,  and  of  little 
comfort  to  the  home  circle.  Circumcision  (of  which  we  found 
great  need)  changed  the  whole  character  of  the  boy,  so  much 
so  that  on  a  recent  visit  the  mother  said  to  me,  "Tell  your 
son  (Dr.  Wallace  Grosvenor  who  performed  the  operation^ 


ORIFICIAL   SURGERY.  567 

that  the  boy  gained  fifteen  pounds  in  weight  since  the  opera- 
tion, eats  a  whole  spring  chicken  for  his  dinner,  and  is  now 
always  happy." 

The  father,  a  man  of  affairs,  asked  in  a  quiet  way  "if 
that  operation  would  do  as  much  for  him  as  it  had  for  the 
boy." 

The  fact  that  insomnia  is  the  high  road  to  insanity,  and 
that  a  very  large  proportion  of  these  cases  may  be  relieved  by 
orificial  methods,  is  my  excuse  for  presenting  this  brief  paper 
before  this  honorable  body  of  distinguished  surgeons. 

Dr.  Dill :  For  five  years  prior  to  April,  1893,  I  was  a  con- 
stant sufferer  from  insomnia  for  the  remainder  of  the  night 
from  about  1  o'clock,  and.  I  am  here  as  a  living  monument  to 
the  results  of  the  orificial  philosophy  at  the  hands  of  Dr.  Pratt. 
He  did  all-round  work  on  me  and  made  a  new  man  out  of  me. 
I  feel  better  now  than  I  have  for  twenty  years. 

Dr.  Curryer:  I  am  a  comparative  novice  in  this,  but  I 
want  to  relate  one  case  of  insomnia.  I  had  a  patient  who  had 
been  unable  to  sleep  for  months,  and  they  said  they  really 
thought  the  woman  was  going  to  lose  her  mind.  I  made  ar- 
rangements to  go  to  her  house,  and  took  a  friend  along  to  ad- 
minister the  anesthetic.  Stretched  the  rectum,  found  a  papilla 
a  quarter  of  an  inch  long,  and  one  or  two  pockets;  gave 
a  thorough  dilatation  and  left  her.  The  second  day  the  friend 
at  whose  house  she  was  staying  came  to  me  and  said:  "We  are 
scared  about  your  patient."  I  said,  "Why,  what  way?"  He 
said,  "We  gave  her  her  supper  and  she  slept  all  that  night — 
the  operation  was  performed  on  Sunday — and  all  day  Mon- 
day, only  arousing  her  to  feed  her,  and  she  slept  till  Tuesday, 
and  we  think  she's  going  to  die."  I  said,  "Let  her  sleep,  and 
she'll  waken  all  right."  The  operation  was  better  than 
morphine. 


568  ORIFIGTAL   SURGERY. 


CHAPTER  LXXIII. 


FUNCTIONAL  INSANITY. 


H.   P.    SKILES.   A.   M..   M.   D. 


Before  reading  my  paper  I  wish  to  quote  from  Dr. 
Spitzka's  work  on  insanity,  page  97.  Speaking  of  the  morbid 
anatomy  of  recent  mania,  he  says:  "In  not  a  single  accurately 
studied  case  has  a  characteristic  lesion  of  the  essential  mental 
apparatus  been  found,  nor  has  any  doubtful  appearance  of  any 
kind  been  discovered  that  has  not  been  found  in  lesser  degree, 
in  sane  persons  also.  The  same  author,  in  quoting  from  M  en- 
del,  says:  "From  all  this  I  draw  the  conclusion  that  mania  is 
a  disease  whose  patho-anatomical  basis  we  have  thus  far  not 
been  able  to  discover  in  the  brain. ' ' 

The  terms  "mental  diseases"  and  "diseases  of  the  brain" 
are  considered  synonymous,  since  it  is  supposed  that  the 
mind  is  located  in  the  brain. 

Accepting  this  as  true,  we  naturally  divide  mental  dis- 
eases into  two  classes,  viz.:  organic,  where  there  is  an  organic 
change  in  the  brain;  and  functional,  where  the  morbid  symp- 
toms are  apparently  from  the  brain,  but  are  rea\ly  produced 
by  some  other  cause. 

It  is  the  latter  class  of  which  I  wish  to  speak  in  this  paper. 

Ordinary  cases  of  aberration  come  under  the  notice  of 
every  physician,  in  general  practice,  and  are  produced  in  va- 
rious degrees  by  any  of  the  acute  diseases,  varying  in  severity 
according  to  the  temperament  of  the  patient.  These,  excepting 
in  very  rare  instances,  pass  away  as  the  disease  subsides  with- 
out any  special  treatment  with  reference  to  the  mental  condi- 
tion, but  those  whose  minds  have  been  turned,  without  acute 
sickness  or  from  no  apparent  cause  claim  our  attention  at  the 
present  time. 

In  this  day,  when  insanity  is  on  the  increase,  it  is  fitting 
for  us  to  inquire  whether  there  is  not  some  way  to  prevent  this 


ORIFICIAL    SURGERY.  569 

terrible  disease,  and  whether  we,  as  physicians,  are  not  in  a, 
measure  responsible  for  permitting  it.  Usually  cases  of  func- 
tional insanity  are  hurried  off  to  the  asylum  where,  with  hun- 
dreds of  others  as  miserable,  they  are  confined,  not  as  a  rule 
for  their  cure,  but  that  they  may  be  detained. 

These  institutions  are  in  a  great  measure  detention  hos- 
pitals. 

In  the  treatment  of  insane  cases  it  is  very  important  that 
we  should  pay  attention  to  the  smallest  details  in  the  symptoms 
of  the  patient ;  not  only  that  we  may  choose  the  proper  remedy, 
but  that  we  may  find  the  cause  of  the  abnormal  condition. 

I  take  it  that  there  is  no  class  of  diseases  that  requires 
closer  observation  than  insanity. 

Patients -suffering  from  this  disease  recover  in  exactly  the 
reverse  order  from  that  in  which  they  were  attacked,  experi- 
encing the  same  delusions  and  aberrations,  though  of  shorter 
duration. 

If  there  is  obtained  a  clear  and  complete  history  of  the 
case  from  the  time  of  his  first  attack,  stating  the  different 
phases  of  his  mania  in  the  exact  order  in  which  they  occurred, 
you  can  tell  exactly  whether  or  not  he  is  improving  and  how 
near  he  is  to  a  normal  condition. 

This  is  a  great  satisfaction  to  anyone  watching  the  grad- 
ual return  of  health.  Considering  that  they  are  hyperaes- 
thetic  in  every  particular,  it  seems  to  me  that  all  local  treat- 
ment should  be  given  while  under  the  influence  of  an  anaes- 
thetic, and  for  these  cases  I  prefer  chloroform. 

For  the  same  reason,  while  they  are  not  considered  re- 
sponsible, they  do  know  a  great  deal  more  than  people  give 
them  credit  for,  and  our  motive  should  be  to  accomplish  the 
restoration  with  as  little  shock  to  the  abnormally  sensitive  or- 
ganization as  possible. 

Again  in  regard  to  deceiving  insane  patients,  great  care 
must  be  observed.  This  should  never  be  done  by  the  physi- 
cian or  attendant,  no  matter  what  others  may  do.  Even  in  the 
matter  of  putting  medicine  in  food,  it  may  cause  a  great  deal 
of  trouble,  for  they  are  just  as  sensitive  to  taste  and  smell  as 
they  are  to  pain  and  are  sure  to  discover  it. 


570  ORIFIC1AL   SURGERY. 

The  character  of  the  attendant  may  to  some  seem  of  little 
importance,  yet  an  attendant  may,  by  a  word,  do  more  harm 
than  a  physician  can  do  good  in  many  days. 

He  should  be  controlled  by  the  same  gentle,  yet  firm  and 
fearless  spirit  that  the  physician  is,  and  must  be  in  harmony 
with  him. 

The  physician  must  have  complete  control  of  his  patient, 
from  the  beginning  of  his  care  until  recovery  is  complete. 

It  is  the  climax  of  all  diseases. 

To  thus  lead  a  patient  for  weeks  and  months,  to  complete 
and  perfect  liberty  of  thought  and  action,  so  that  he  who  was 
once  a  raving  maniac,  is  again  a  sentient  being,  is  a  work 
worthy  of  the  deepest  thought  and  greatest  effort. 

The  satisfaction  derived  from  thus  lifting  one  from  misery 
indescribable,  and  restoring  him  to  his  family  and  friends,  is 
sweet  and  deep. 

I  wish  to  give  a  few  cases  to  illustrate. 

Case  1.  Was  taken  from  a  private  asylum  in  July,  1887. 
She  had  been  insane  for  twenty  years,  according  to  the  records 
of  the  court.  Sixty-two  years  of  age,  mother  of  a  large  family. 

At  times  she  was  vicious,  restless,  talking  a  great  deal, 
sleeping  from  one  to  two  hours  per  night,  swearing  a  greater 
part  of  the  night,  and  was  considered  beyond  all  help  by  the 
learned  superintendent,  he  saying  that  her  physical  condition 
was  perfect,  that  her  condition  was  the  effect  of  a  diseased 
brain. 

The  next  day  under  chloroform,  I  made  an  examination, 
not  of  the  brain,  but  to  find  if  there  was  not  other  cause  that 
had  produced  her  mania. 

She  knew  enough  to  tell  me  that  she  was  burning  up  right 
down  through  her  body  and  that  she  vomited  a  great  deal. 

My  examination  revealed  a  retroflexed  uterus,  slightly 
lacerated,  a  prolapsed  rectum  exposing  about  two  inches  of 
the  mucous  membrane.  This  portion  of  the  rectum  was  ampu- 
tated and  the  patient  put  to  bed. 

She  improved  so  much  in  sleep  that  at  the  end  of  the  first 
ten  days  she  was  sleeping  most  of  the  night,  in  spite  of  the 


ORIFICIAL   SURGERY.  571 

fact  that  with  our  facilities  we  were  unable  to  keep  her  in 
bed  longer  than  a  few  hours  after  the  operation. 

At  the  end  of  three  weeks  her  husband  met  me  as  I  made 
my  morning  call  and  said  he  was  much  encouraged,  that  his 
wife  was  going  back  over  the  road  she  came. 

The  first  noticed  when  she  lost  her  reason  that  she  found 
fault  with  her  husband  and  his  people,  and  from  this  became 
very  violent  and  was  adjudged  insane.  Next,  she  thought 
everything  had  a  bad  odor,  and  then  that  everything  was  poi- 
son, food,  ornaments,  pictures,  etc.  At  last  she  saw  floating 
through  the  air,  parts  of  the  bodies  of  friends  and  children  and 
she  would  converse  with  them.  This  stage  continued  until 
about  three  weeks  after  the  operation  when  she  began  to  talk 
about  the  poison,  until  finally  she  spoke  only  of  the  poison 
that  surrounded  her.  This  remained  for  some  time  when  it 
was  dropped  for  the  odors  that  seemed  to  her  to  permeate 
everything. 

Finally  came  the  "tug  of  war."  The  vials  of  wrath  that 
had  been  stored  up  for  twenty  years  against  her  husband  and 
his  people  were  poured  out.  This  lasted  about  ten  days  when 
she  became  quiet  and  peaceable  most  of  the  time. 

It  has  now  been  nearly  five  years  since  she  had  any  treat- 
ment and  she  has  had  no  attendant.  The  retroversion  I  was 
unable  to  cure  and  she  is,  of  course,  nervous  and  easily  ex- 
cited. She  is  at  liberty  to  go  and  come  as  she  wishes,  goes  out 
calling  and  to  church.  Principal  remedy,  arsenicum. 

Case  2.  In  January  of  1888  I  was  called  to  see  Mrs.  P.,  22 
years  of  age,  married,  one  baby  17  months  old. 

I  found  her  violently  insane  with  a  temperature  of  104 
degrees,  requiring  three  persons  to  keep  her  from  throwing 
herself  from  a  second  story  window. 

There  was  an  abscess  in  the  left  breast,  as  the  exciting 
cause  of  the  fever  and  delirium.  The  abscess  was  opened  and 
in  a  few  days  the  fever  was  controlled,  but  the  delirium  re- 
mained, requiring  constant  attention  and  vigilance  to  keep  her 
under  control. 

I  informed  the  friends  that  it  was  my  opinion  that  there 
was  some  trouble  with  the  uterus. 


572  ORIFIG1AL   SURGERY. 

Under  chloroform,  an  examination  revealed  sub-involution 
of  the  uterus,  the  depth  of  which  was  eight  inches  and  retro- 
verted. 

Secale  was  ordered  three  times  a  day  in  small  doses.  Cer- 
vix was  dilated  and  uterus  replaced. 

It  was  with  great  difficulty  that  she  was  fed  enough  to 
sustain  her. 

I  informed  the  friends  that  she  would  not  improve  men- 
tally until  the  uterus  regained  its  normal  condition. 

This  was  accomplished  by  treating  under  chloroform  every 
ten  days  or  two  weeks  for  two  and  one-half  months,  after 
which  she  made  a  rapid  and  perfect  recovery,  and  has  re- 
mained in  perfect  health  since. 

Beside  secale,  aconite  and  belladonna  were  used  accord- 
ing to  their  indications. 

Case  3.  Mr.  A.,  aged  62,  was  brought  to  me  November 
1st,  1891. 

He  had  been  ailing  for  two  years  or  more. 

Could  not  even  tell  his  name  or  place  of  residence. 

He  had  been  a  man  of  more  than  ordinary  intellect ;  an  ex- 
member  of  the  legislature  of  Kansas. 

He  was  cyanotic  in  the  extreme,  lips,  finger  nails,  etc., 
blue,  so  much  so  that  I  was  afraid  to  give  him  an  anaesthetic. 
I  put  him  into  bed  and  waited  two  days  to  see  if  there  might 
be  some  improvement  from  rest.  As  none  came,  I  began  the 
treatment  with  a  great  deal  of  trepidation. 

Keeping  him  under  the  influence  of  chloroform  only  for  a 
few  minutes,  I  dilated  the  rectum  and  passed  sounds  in  ureth- 
ra. Reaction  was  good;  hot  applications  were  applied  locally 
for  three  hours,  with  good  effect.  At  the  end  of  that  time,  in 
accordance  with  the  desire  of  the  patient,  they  were  discon- 
tinued, which  we  soon  found  was  a  great  mistake. 

In  two  hours  he  had  a  chill  and  collapse.  Aconite  every 
few  minutes  and  the  hot  applications  again  restored  him.  From 
this  he  improved  rapidly.  At  the  end  of  a  week  he  was  again 
treated. 

Beside  his  mental  trouble,  he  had  a  sloughing  heel  which 
also  improved  as  the  circulation  was  improved. 


ORIFIGTAL    SURGERY.  573 

His  aberrations  were  reproduced  in  exactly  the  reverse 
order,  as  we  learned  from  the  son's  statement  which  we  re- 
ceived at  the  end  of  the  second  week.  At  the  close  of  five  weeks 
he  was  taken  home  in  his  right  mind. 

I  would  state  here  that,  as  a  rule,  it  takes  from  two  to  lour 
months  to  permanently  relieve  one  of  these  cases.  Aconite, 
nux  vom.,  aloes  and  arsenicum  were  the  remedies  used.  Prin- 
cipally, aloes. 

Case  4.  Mrs.  R.,  aged  27,  was  seen  the  latter  part  of 
March,  1891,  and  I  found  the  following  history. 

She  had  undergone  an  operation  for  lacerated  cervix,  and 
after  she  began  to  convalesce,  showed  signs  of  insanity.  This 
increased  until  she  had  to  be  kept  with  an  attendant  continu- 
ally. After  having  her  under  remedies  for  several  days,  I  put 
her  under  chloroform  and  dilated  the  cervix  and  also  the  rec- 
tum thoroughly,  as  I  found  it  was  ulcerated. 

There  was  no  improvement  in  her  mental  condition  and  for 
several  weeks  I  tried  keeping  her  quiet  and  giving  remedies. 
It  was  all  of  no  avail.  She  became  more  violent  until  we  were 
finally  obliged  to  restrain  her  by  force. 

On  July  15th,  I  reopened  the  cervix  and  removed  the 
cicatricial  tissue  and  again  replaced  the  sutures  for  its  repair. 
From  this  treatment  her  improvement  was  gradual  and  com- 
plete. It  was  more  than  two  months  before  I  removed  the 
sutures. 

She  has  remained  in  good  health  since. 

Case  5.  Mrs.  H.,  aged  32,  the  mother  of  four  children,  had 
been  ailing  several  years.  I  was  called  the  last  of  March,  1892. 
Found  her  suffering  from  melancholia,  being  able  to  talk  with 
a  great  deal  of  difficulty  and  very  much  frightened.  This  was 
the  most  severe  and  stubborn  case  in  regard  to  taking  any  kind 
of  nourishment  that  I  have  ever  seen. 

For  five  weeks  we  were  compelled  to  feed  her  by  means  of 
a  tube.  She  would  not  even  take  a  swallow  of  water. 

On  examination  we  found  the  cervix  was  lacerated,  the 
vagina  eczematos  and  the  rectum  ulcerated. 

April  1st,  under  chloroform,  I  dilated  cervix  curetted 
with  cotton,  also  treated  ulcers  of  rectum  by  dilatation. 


574  ORIFIC1AL    SURGERY. 

From  this  we  had  some  general  improvement  so  that  on 
May  15th,  operated  for  lacerated  cervix. 

Mental  condition  so  bad  that  we  were  unable  to  keep  any 
clothing  on,  excepting  a  night  dress  of  ducking. 

June  15th,  under  chloroform,  I  found  a  severe  impaction 
above  the  rectum  which  was  relieved  by  hand. 

From  this  date,  improvement  was  marked  and  very  rapid. 

Early  in  July  she  was  able  to  go  out,  and  by  July  15th  I 
was  able  to  pronounce  her  in  perfect  health ;  she  has  been  able 
to  take  charge  of  her  household  better  than  she  has  done  for 
years. 

I  might  continue  to  recite  cases,  but  these  are  enough  to 
illustrate  what  has  been  done  and  what  may  be  done  again. 

It  also  shows  that  every  one  of  these  cases  might  have  been 
prevented  very  much  easier  than  they  were  cured. 

[It  will  be  observed  that  these  cases  were  treated  a  score 
or  more  years  ago.  Since  then  many  advances  have  been  made 
in  the  orificial  thought  and  new  methods  of  its  application  dis- 
covered. I  am  sure  all  these  cases  would  have  improved  much 
more  rapidly  under  all-round  orificial  surgery  as  it  is  done  to- 
day. There  was  more  or  less  gross  pathology  manifested  in 
each  case  which  received  attention,  but  the  clitoris  was  ig- 
nored ;  only  the  gross  pathological  condition  of  the  rectum  cor- 
rected ;  the  meatus,  prepuce  and  frenum  not  mentioned. 

Dr.  Skiles  has  given  us  a  valuable  chapter,  which  is  worthy 
of  careful  reading,  and  the  cases  reported  show  the  marvelous 
results  of  this  work  in  this  gloomy  field  of  mental  stubble.  If 
doctors  could  only  be  brought  to  a  realization  of  the  great 
potency  of  this  measure  in  curing  functional  insanity,  what  a 
wonderful  benediction  it  would  bestow  upon  humanity!  It 
would  enter  many  homes  as  a  welcome  guest,  bringing  sunshine 
and  laughter  where  gloom  and  tears  abide.  Our  insane  asy- 
lums, now  full  to  overflowing,  and  are  only  places  where  these 
unfortunate  beings  are  restrained,  clothed  and  fed,  could  be 
relieved  of  three-fourths  of  their  inmates,  sent  home  clothed  in 
their  right  minds,  and  nine-tenths  of  those  being  sent  there 
could  be  kept  at  home  by  preventive  measures. — Editor.] 


OKIFIGTAL    SURGERY.  575 


CHAPTER  LXXIV. 


NEURASTHENIA. 


C.    E.    SAWYER,   M.   D. 


Neurasthenia  is  a  chronic  functional  disease  of  the  nerv- 
ous system  with  deficient  nerve  force  and  a  constant  liability 
to  exhaustion. 

There  are  two  types  of  the  disorder — anemic  and  hyper- 
emic.  In  the  anemic  type  there  is  a  disposition  to  apathy,  dull- 
ness and  listlessness,  accompanied  with  a  general  appearance 
of  mal-nutrition.  In  the  hyperemic  variety  the  chief  mani- 
festations are  those  of  excitement,  nervousness  and  constant 
unrest,  while  the  general  appearance  may  not  indicate  other 
than  a  favorable  physical  condition. 

In  each  class,  however,  we  find  the  same  general  symptoms. 
They  all  live  in  a  state  of  nervous  bankruptcy  and,  unaided, 
become  hopeless  invalids,  sooner  or  later  surrendering  the 
citadel  of  their  existence  to  some  intercurrent  disease,  which 
the  inroads  of  neurasthenia  have  made  accessable. 

Neurasthenia  may  originate  from  some  emotional  strain  or 
mental  depression  involving  a  constant  irritation  of  the  feel- 
ings. It  may  also  arise  from  poor  hygienic  surroundings  and 
improper  diet.  Not  infrequently  acute  diseases  lapse  into  just 
such  conditions.  Many  people  unknowingly  live  in  a  state  of 
nervous  extravagance  which  when  comparatively  well  they 
manage  to  support  without  any  appreciable  effect,  but  when 
the  overdraft  of  some  apparently  slight  acute  disease  is  made 
upon  their  vital  bank  account  they  are  never  able  to  recover. 

In  my  personal  experience,  nine-tenths  of  all  cases,  both 
male  and  female,  are  reflex,  and  ninety  per  cent,  of  these  arise 
from  some  sexual,  generative  or  rectal  disorder. 

In  symptomatology  there  is  no  other  disease  so  replete. 
Chief  among  them  are  sleeplessness,  dizziness,  weakness, 
numbness,  ringing  and  roaring  in  the  ears,  floating  specks  be- 


576  ORIFIdAL    SURGERY. 

fore  the  eyes,  cold  hands  and  feet,  irritability,  petulance,  im- 
patience, uncertainty  of  conduct,  morbid  fears  and  vain  im- 
aginings. 

Neurasthenics  are  dejected,  melancholy,  despondent  and 
distrustful.  Having  tried  the  young  doctor,  the  old  doctor, 
the  specialist,  the  quack,  and  the  patent  medicine  vender  alike 
without  relief,  they  have  lost  confidence  in  things  both  human 
and  supernatural.  Having  lost  control  of  the  balance  wheel 
of  their  nervous  machine,  they  become  a  source  of  discomfort 
to  their  family  and  a  burden  to  themselves  and  friends;  they 
are  afloat  on  a  rough  and  dangerous  sea  without  compass  or 
rudder  to  guide  them.  Their  condition  is  a  pitiable  one  indeed. 

Every  community  has  them,  every  physician  sees  them. 
They  are  chronic  invalids  found  in  the  homes  of  the  rich  and 
poor  alike. 

They  are  the  most  abused,  neglected  and  maltreated  class 
of  individuals  on  earth.  Their  neighbors  accuse  them  of 
being  hysterical  and  their  physician,  unless  he  be  an  observing 
man  and  awake  to  the  necessities  of  suffering  humanity,  con- 
soles himself  with  the  thought  that  their  condition  is  only 
imaginary.  These  charges  may  be  true,  but  I  do  not  believe 
this  vast  army  of  complainers  are  so  from  choice  and  without 
cause. 

The  following  cases  illustrate  the  two  types  of  the  disorder 
and  the  line  of  treatment  that  my  experience  has  found  most 
useful. 

Miss  H.,  aged  20  years,  blonde.  Family  history,  fairly 
good.  At  the  age  of  fifteen  years  had  an  attack  of  remittent 
fever,  from  which  lapsed  into  one  of  anemic  neurasthenia,  re- 
maining bedridden  for  five  years,  two  years  of  which  she  was 
swung  in  a  hammock  night  and  day. 

Every  one  was  excluded  from  her  apartments  but  her  at- 
tendants. At  times  the  faintest  ray  of  light,  the  slightest  noise 
would  make  her  so  nervous  as  to  require  hours  of  soothing  to 
overcome  its  effect.  For  days  and  nights  together  she  would 
not  sleep  one  hour  out  of  the  twenty-four. 

At  my  first  visit  I  found  her  bathed  with  perspiration,  her 
hands  and  feet  cold,  her  face  pale,  her  expression  drawn  and 


ORIFIGIAL    SURGERY.  577 

distressed,  her  teeth  decaying,  her  hair  short  and  stubby,  her 
muscles  soft  and  flabby. 

She  could  not  raise  her  head  to  take  a  drink  of  water 
without  help. 

Her  pulse  rate  was  120  beats  per  minute,  her  bowels  were 
constipated  and  her  menses  suppressed.  Her  whole  appear- 
ance was  that  of  general  anemia. 

Her  family  physician,  with  whom  I  was  called  in  consulta- 
tion, assured  me  that  he  had  exhausted  every  remedy  in  the 
Materia  Medica  in  his  efforts  to  afford  relief. 

[This  patient  was  taken  from  her  home  and  for  four  months 
Dr.  Sawyer  assiduously  tried  medication,  mental  impressions 
and  electricity,  with  but  little  if  any  benefit.  The  following  year 
she  was  placed  in  his  sanitarium  and  a  physical  examination 
made  which  was  heretofore  denied.  Following  he  relates  her  con- 
dition and  treatment. — Editor.] 

All  of  the  pelvic  viscera  were  engorged.  The  os  uteri  was 
but  a  pin  hole,  and  the  sphincters  were  all  tight  and  un- 
yielding. 

I  at  once  did  forcible  dilatation,  and  in  less  than  forty- 
eight  hours  the  outpouring  of  vital  force  had  ceased.  The 
victim  of  reflex  irritation  was  released  from  her  thraldom.  All 
that  remained  necessary  to  complete  her  cure  was  to  afford  her 
every  opportunity  of  regaining  strength,  which  we  did  by 
bringing  to  bear  the  same  influences  that  had  failed  the  year 
before,  and  in  less  than  two  months  she  was  discharged  a  well 
woman. 

Mr.  C.,  aged  55  years;  married,  farmer.  Was  attacked 
with  la  grippe.  After  the  acute  symptoms  had  subsided,  he 
continued  poorly. 

[Here  the  doctor  relates  the  development  of  the  neuras- 
thenic condition.  How  the  patient  became  restless,  walking  the 
floor  for  hours,  like  a  caged  hyena,  .then  dejected  and  depressed; 
grew  steadily  worse,  threatening  his  own  life,  as  well  as  that  of 
others.  How  for  six  weeks  he  left  no  means  untried  in  the  way 
of  medication  and  saw  his  patient  growing  desperately  worse. — 
Editor.] 

Physical  examination  revealed  tight  sphincters,  with  two 
irritable  pile  tumors,  feur  large  pockets  and  an  enlarged  pros- 
tate. Under  ether  I  did  the  slit  operation,  remove  dthe  pock- 
ets and  dilated  the  urethra. 


578  ORIFIGTAL   SURGERY. 

On  the  eighth  day  following  the  operation  I  began  massage 
and  general  Faradisation.  Today  he  is  a  well  man.  I  do  not 
cite  these  cases  because  I  cured  them,  for  any  progressive 
physician  could  have  done  the  same,  but  rather  to  show  the 
necessity  of  seeking  diligently  for  the  cause,  and  when  once 
found  thoroughly  and  unhesitatingly  removing  it. 

Most  cases  of  neurasthenia  are  curable,  but  there  is  a  time 
when  they  have  crossed  the  border  line  and  succor  comes  too 
late.  This  is  when  the  nerve  centers  have  been  starved  so  long 
that  atrophic  changes  have  taken  place  in  them. 

CHAPTER  LXXV. 


CHRONIC  CONSTIPATION. 


T.   E.   COSTAIN,   M.   D. 


Anatomically  considered,  all  the  functional  activities  are 
presided  over  by  the  sympathetic  nerve  mainly,  although  the 
communicating  rami  in  the  cervical  and  sacral  regions  may 
play  an  important  part  both  directly  and  reflexly. 

Constipation  itself  being  merely  a  symptom  of  a  neurotic 
condition,  the  cause  of  this  trouble  must  be  looked  for  in  a 
general  or  local  neurosis. 

Constipation  essentially  belongs  among  the  affections  of 
the  sympathetic  nerve,  due  to  a  loss  of  tone,  or  lowered  vi- 
tality of  this  nerve,  the  causes  of  which  are  many:  brain  or 
spinal  cord  lesions,  improper  or  irregular  diet,  alcoholism,  sex- 
ual excesses,  pathological  conditions,  such  as  hemorrhoids, 
pockets,  papillae,  fissures  or  fistulae  disturbing  the  anal  sphinc- 
ters. Chronic  constipation  depends  on  perverted  action  of  the 
muscular  coat  of  the  intestines  presided  over  by  Auerbach's 
plexus,  or  may  be  due  to  a  prolonged  spasm  of  the  sphincter 
muscles  which  are  supplied  by  both  cerebro-spinal  and  sympa- 
thetic. Physiology  teaches  us  that  immediately  after  the  ex- 
pulsion of  feces  the  sphincter  muscles  contract  vigorously  and 
remain  so  for  some  time.  This  is  due  to  the  irritation  of  the 


ORIFIG1AL    SURGERY.  579 

nerve  terminals.  How  much  more  contraction,  then,  do  we 
have  when  pathological  lesions  of  the  rectum  serve  to  con- 
stantly irritate  these  nerve  terminals,  producing  an  almost  con- 
stant spasm  of  the  sphincter  muscles.  The  nervous  manifesta- 
tions ruling  the  small  intestines  differ  somewhat  from  those  of 
the  large,  the  nerves  ruling  the  small  intestines  acting  more 
vigorously  and  with  greater  rapidity,  while  the  nerves  of  the 
large  intestines  act  slower.  The  slower  action  is  due  to  the 
inferior  mesenteric  plexus.  We  find  in  the  walls  of  the  intes- 
tines plexuses  known  as  Meissner's,  which  control  the  secre- 
tion of  the  mucous  membrane,  and  Auerbach's,  which  control 
the  muscular  action.  Both  these  plexuses  are  a  part  of  the 
sympathetic  nerve  and  controlled  by  that  nerve,  so  that  a 
weakened  sympathetic  means  a  perverted  muscular  action  or 
secretion  due  to  a  lack  of  nerve  force. 

Especially  is  this  true  of  the  part  supplied  by  the  inferior 
mesenteric  plexus,  the  action  of  this  nerve  nominally  being 
slow,  and  it  supplies  that  part  of  the  large  intestines  where  the 
fecal  masses  lie  after  most  of  the  moisture  has  been  removed. 
The  function  of  Meissner's  plexus  being  to  preside  over  the 
mucosa  with  its  numerous  glands,  if  perverted,  the  feces  cake 
and  often  adhere  to  the  walls  of  the  intestines,  further  pre- 
venting peristalsis.  In  this  way  it  is  often  possible  by  a  subse- 
quent hyperesthetic  state  of  this  same  plexus  to  bring  on  a 
diarrhoea,  and  the  patient  still  remain  constipated,  because  all 
the  fecal  mass  does  not  come  away. 

Perverted  functional  activity  of  either  Auerbach's  or 
Meissner's  plexus  can  be  the  cause  of  either  a  ptomaine  or 
toxin  poison  of  the  system.  The  bacteria  normally  found  in  the 
intestines  by  an  excess  of  culture  media  may  multiply  rapidly, 
and,  nature's  sentinels  being  a  little  sleepy,  allow  them  full 
play  at  their  dangerous  work  of  poisoning  the  system,  and  un- 
less these  sentinels  suddenly  wake  up  to  their  sense  of  duty, 
material  damage  to  the  system  is  apt  to  result.  Cases  of  this 
kind,  where  the  temperature  and  pulse  have  been  abnormally 
high  and  all  the  symptoms  of  typhoid  state  seemed  present, 
but  which  all  vanished  in  from  one  to  three  days,  have  come 
to  my  notice. 


580  ORIFIG1AL   SUKGERY. 

Structural  changes  in  the  brain  and  spinal  cord  can  re- 
flexly  produce  all  of  these  same  conditions,  but  are  at  all  times 
obvious,  and  temporary  expedients  often  have  to  be  resorted 
to,  to  overcome  these  conditions,  because  to  cure  them  under 
these  circumstances  the  cause  must  first  be  removed.  Where 
the  sympathetic  is  the  cause,  the  conditions  which  have  pro- 
duced the  loss  of  this  power  must  be  attacked  in  order  that  a 
permanent  cure  may  result. 

The  predisposing  causes  having  been  removed,  a  perma- 
nent cure  cannot  always  be  had  unless  the  existing  causes  are 
carefully  treated;  this  means  to  secure  a  better  peristaltic 
action  or  an  increased  secretion  of  the  intestines,  especially 
the  left  half  of  the  colon,  sigmoid  and  rectum,  where  the  feces 
normally  lie,  and  which  is  presided  over  by  the  inferior  me- 
senteric  plexus.  To  accomplish  this  the  diet  must  be  cor- 
rected and  a  diet  given  which  shall  have  a  larger  amount  of 
waste  product  to  act  as  a  stimulus  to  peristaltic  movement. 

The  solids  and  fluids  play  an  important  part  in  the  forma- 
tion of  the  stool.  Water  is  one  of  the  best  adjuvants.  A  glass 
of  warm  water  with  a  little  salt  taken  on  rising  is  often  found 
to  be  of  great  value.  Regular  habits,  too,  play  an  important 
part  and  patients  should  always  be  instructed  to  go  to  stool 
regularly  every  morning  after  breakfast,  as  the  warm  contents 
of  the  stomach  at  that  time  aid  in  increasing  peristalsis.  Hy- 
gienic conditions  should  be  regulated;  a  salt  brine  bath  with 
a  vigorous  rub  following,  stimulates  the  circulation  and  is  of 
value. 

Exercise,  too,  is  a  valuable  aid.  A  study  of  the  sympa- 
thetic nerve  must  after  all  be  your  chief  reliance.  How  can  it 
be  stimulated  to  an  increased  action  in  order  that  it  may  meet 
its  daily  demands.  Massage,  pressure  or  vibratory  movements 
of  the  solar,  hypogastric  or  pelvic  plexus  give  a  direct  stimu- 
lus and  bring  to  life  the  vitality  of  the  branches  which  control 
peristalsis.  Hydro-therapy  or,  better  still,  hydro-electro- 
therapy, also  gives  you  another  means  by  which  a  direct 
stimulus  can  be  given  to  the  nerves  governing  that  part  of  the 
intestine  most  often  involved.  The  indicated  remedy  should 


ORIFIG1AL   SURGERY.  581 

not  be  overlooked  before  or  during  this  treatment.  So  many 
remedies  are  indicated  in  constipation  that  I  shall  refrain  from 
naming  any  of  them;  suffice  to  say,  don't  neglect  them  if  you 
want  to  cure  your  patient. 

CHAPTER  LXXVI. 


CONSTIPATION  AND  DIARRHEA  AS  A  NEUROSIS; 
TREATMENT  FROM  AN  ORIPICIAL  STANDPOINT. 


J.   W.  MEANS,   M.   D. 


Constipation  is  originally  from  the  Latin  Con,  meaning 
together,  and  stipare,  to  fill  up. 

Diarrhea  is  a  word  derived  from  the  Greek,  meaning  to 
flow  through.  Osier  defines  constipation  as  retention  of  feces 
from  any  cause,  diarrhea  as  catarrhal  enteritis. 

The  definitions  given  in  the  text  books  are  superficial  and 
meaningless — dealing  with  results  rather  than  causes.  Upon 
what  do  the  phenomena  known  in  common  parlance  as  diar- 
rhea and  constipation  depend? 

First,  we  have  central  or  peripheral  irritation  in  diarrhea, 
and  central  or  peripheral  paralysis  in  constipation.  When 
central  in  either  case  the  term  chronic  is  usually  applied ;  when 
peripheral,  the  term  acute  is  used.  Chronic  conditions  are  deep- 
seated,  more  obscure  and  hard  to  cure;  while  acute  states  are 
usually  self-limited  and  induced  by  local  causes.  In  a  broad 
sense  constipation  is  that  condition  arising  from  a  sub-normal 
state  of  the  nerves  supplying  the  mucous  membrane  of  the  di- 
gestive tract,  inducing  partial  or  complete  paralysis.  Diar- 
rhea is  a  super-normal  action  of  the  same  nerves  supplying  the 
mucous  membrane  of  the  same  organs.  So  in  either  condition 
the  great  organic  nervous  system  is  at  fault,  and  to  restore  it 
to  its  normal  state  is  the  object  of  treatment. 

Chronic  diarrhea  and  chronic  constipation  cannot  be 
cured  or  materially  benefited,  unless  the  nervous  system  sup- 
plying the  capillaries  of  the  mucous  membrane  of  the  bowels  be 


582  ORIFIC1AL   SURGERY. 

restored  to  a  state  of  normality.  In  fact  the  nerve-centers  are 
the  magazines  of  the  body  and  the  slender  fibers  leading  there- 
from are  the  avenues  through  which  impressions  are  transmit- 
ted. The  great  central  ganglion  located  in  the  calvarium  domi- 
nates the  minor  centers.  They  are  held  in  subjection  by  cen- 
tripetal force  as  the  sun  controls  the  planets  of  the  solar  sys- 
tem. Impressions  made  upon  the  nerves  of  special  sense  affect 
the  salivary  and  gastric  secretions ;  sight,  smell,  taste  and  even 
thought  of  food  stimulate  the  flow  of  saliva.  A  change  in  tem- 
perature, fright,  change  in  constitution  of  the  intestinal  se- 
cretions, will  produce  diarrhea  or  constipation. 

Congestion  of  the  solar  plexus  either  as  a  result  of  blows 
on  the  abdomen,  or  from  iodopathic  causes,  has  often  been 
found  associated  with  excessive  diarrhea.  The  abdominal  brain 
stands  as  a  monitor  of  the  visceral  functions.  The  sphincter 
muscles  are  kept  in  a  state  of  tonic  contraction  by  a  nerve- 
center  situated  in  the  lumbar  portion  of  the  spinal  cord.  In 
short,  both  above-named  diseases  are  dependent  upon  the  ab- 
normal action  of  the  sympathetic  nervous  system.  Health  is 
the  result  of  the  harmonious  action  of  the  functions  of  the 
body.  Hence  to  be  in  perfect  health,  the  brain  situated  at  the 
top  of  the  spinal  cord  must  receive  from  its  subordinates 
healthful  impressions — not  only  healthful  impressions,  but 
there  must  be  intervals  of  complete  rest.  The  constant  nag- 
ging and  appeals  of  an  irritated  nerve  for  help,  exhausts  the 
humor  and  vital  power  of  the  imperial  dictator,  when  a  general 
deterioration  of  the  whole  nervous  system  follows.  The  rhyth- 
mic action  of  the  once  harmonious  network  of  delicate  nerve 
filaments  no  longer  exists  and  neuralgia,  dyspepsias,  headaches, 
indigestions,  in  fact  disorder  reigns  supreme,  until  relief  by 
mechanical  or  medicinal  means  is  found. 

What  have  we  done  to  alleviate  these  common  but  in- 
tractable disorders? 

The  materialist  turns  to  the  pharmacopea,  and  there  se- 
lects the  most  powerful  astringents  or  cathartics  and  dopes  his 
patient  therewith.  He  so  abuses  nature  with  his  so-called 
remedies  that  she,  with  indignation,  arouses  her  latent  ener- 


ORmOLAL   SURGERY.  583 

gies  to  throw  off  the  intruder,  and  in  so  doing  reinvigorates 
the  whole  economy  so  that  health  is  restored  in  many  cases. 

The  ccm.  theorist  after  exhausting  the  catechism  and  very 
often  his  patient  with  his  interminable  array  of  technical  in- 
terrogatories, adroitly  passes  beneath  the  organ  of  olfaction 
an  uncorked  vial  from  which  emanates  double  distilled,  dyna- 
mized wrath,  which  grapples  with  the  monster  disease  so  deftly 
yet  so  heroically  that  the  sentinels  of  the  central  ganglia  are 
not  aware  of  the  great  intestinal  struggle  going  on. 

Time  is  a  great  factor  with  both  these  experimenters.  The 
former  has  the  experience  of  2,000  years  behind  him.  The 
latter  has  the  reserved  powers  of  nature  to  aid  him  which  he 
incorrectly  interprets  as  dynamic  drug  action. 

What  treatment  should  be  adopted? 

First,  dilate  the  rectum  once  a  week  with  a  Pratt  dilator. 
This  had  better  be  done  without  an  anesthetic  as  the  shock  in- 
cident to  the  use  of  the  dilator  without  an  anesthetic  is  more 
profound  than  with  an  anesthetic.  In  my  opinion  there  is  no 
shock  without  sensation.  When  the  sensibilities  are  benumbed 
with  powerful  anesthetics,  the  beneficial  effects  arising  from 
dilatation  of  the  sphincters  are  local  only.  The  nervous  fila- 
ments need  coaxing  instead  of  such  sudden  forcing  as  is  usually 
used,  and  the  whole  system  gains  more  from  gentle  and  persist- 
ent effort  than  from  one  mad  rush  like  a  torrent  down  a  moun- 
tain side.  I  care  not  whether  it  be  constipation  or  diarrhea, 
dilatation  will  in  chronic  cases  do  more  to  re-establish  the 
tonicity  of  the  ganglionic  nervous  system  supplying  the  in- 
testinal tract,  than  any  other  method  known.  There  are  adju- 
vants useful  and  needed  in  many  cases,  but  these  when  used 
alone  fail  to  meet  the  demands  of  the  healing  art.  Flushing 
the  bowels  has  its  advantages  and  its  disadvantages,  but  when 
used  in  conjunction  with  dilatation  great  benefit  is  derived. 
Not  only  is  it  necessary  to  dilate  the  sphincter  ani  muscles, 
but  a  large  per  cent,  of  the  lesions  under  consideration  are  a 
result  of  narrowing  of  the  sigmoid  flexure,  hence  dilatation  of 
that  region  is  necessary.  Statistics  show  that  87  per  cent,  of 
what  have  been  termed  chronic  and  incurable  cases,  by  all  or- 


584  ORIFIC1AL   StTRGEBY. 

dinary  methods,  are  so  materially  improved  that  the  term 
cured  is  applicable. 

Second,  circumcision.  In  cases  of  marasmus  in  children, 
clipping  the  foreskin  often  completely  cures  a  long  standing 
diarrhea.  In  twenty-four  operations  for  circumcision  at  least 
50  per  cent,  of  these  cases  had  diarrhea,  all  of  which  were 
cured. 

Don't  understand  me  to  say  that  dilatation  and  circum- 
cision are  the  only  methods  to  be  adopted,  but  I  wish  to  empha- 
size this  one  point:  Pay  special  attention  to  the  sympathetic 
nervous  system  and  relieve  all  impingements  of  the  terminal 
nerve  filaments. 

CHAPTER  LXXVII. 


CONSTIPATION. 


B.   E.   DAWSON,   M.   D. 


Observation  and  study  of  this  subject  have  convinced  me 
that  it  has  not  received  the  attention  at  the  hands  of  the  prac- 
tician that  its  importance  demands.  Many  of  us  are  not  only 
guilty  of  the  sin  of  omission  against  this  functional  disturb- 
ance, but  our  treatment  is  injurious. 

It  is  useless  to  enumerate  the  train  of  evils  following  or 
accompanying  constipation ;  we  are  all  familiar  with  them.  A 
moment's  reflection  brings  them  before  us  in  such  a  view  as  to 
plainly  spell  disaster  and  confusion  among  the  viseral  mem- 
bers of  the  family  of  our  patient's  body. 

A  physician  who  prescribes  a  cathartic,  laxative,  or  medi- 
cation of  any  kind  upon  the  diagnosis  of  constipation  by  the 
patient,  is  unworthy  the  name.  He  is  stepping  down  in  line 
with  the  quack  and  patent  medicine  vender,  much  lower  than 
the  old  woman  who  mothers  and  doctors  the  neighbors  with 
her  "yarbs"  and  teas. 

A  case  of  constipation  imperatively  demands  a  searching, 
thorough  examination  from  the  upper  to  the  lower  openings  of 


ORIFIGIAL   SURGERY.  585 

the  body.  The  diagnosis  is  not  simply  to  ascertain  how  often 
or  how  seldom  the  evacuation  of  feces  takes  place.  There  are 
numerous  other  concomitants  which  should  be  searched  out 
and  placed  in  the  column  before  adding  up  to  get  the  sum 
total.  Not  only  the  physical  examination  is  required,  but  every 
chapter,  paragraph,  line  and  word  in  the  history  of  the  case 
must  be  closely  studied. 

Keep  before  you  all  the  time  that  constipation  is  a  neurosis 
of  the  fecal  reservoir — under  the  domain  of  the  sympathetic 
system.  The  fecal  reservoir — left  half  of  the  transverse  colon, 
descending  colon,  sigmoid  and  rectum — presided  over  by  the 
inferior  mesenteric  ganglion,  must  be  considered  by  a  study 
of  its  several  elements.  Its  mucous,  muscular  and  serous  coats ; 
its  blood  and  nerve  supply.  We  must  also  remember  there  is 
a  four-fold  function,  presided  over  by  the  sympathetic,  making 
a  factor  involved  in  constipation,  not  to  be  ignored.  We  have 
sensation,  peristalsis,  secretion  and  absorption;  any  one  or  all 
of  the  members  of  this  quartet  may  be  at  fault.  As  the  four 
strings  of  a  violin  must  be  tuned  in  harmony  to  avoid  discord, 
so  must  these  four  be  and  remain  in  harmony.  A  free  flow  of 
fresh  blood  supply  to  the  bowel  wall  is  necessary  to  the  perfect 
work  of  this  quartet.  A  deficient  supply  of  blood  could  slow 
peristalsis  or  check  secretion  when  constipation  will  result — 
an  index  finger  pointing  toward  the  line  of  treatment  need- 
ed. A  good  pure  blood  stream  is  the  agent  that  removes  path- 
ology of  any  form  when  it  can  be  removed.  Its  absence  invites 
pathological  conditions.  The  menstrual  flow  often  so  entices 
the  blood  from  the  colon  as  to  cause  defective  peristalsis  and 
produce  constipation  as  a  concomitant;  so  with  chronic  con- 
gestion or  inflammation  of  the  sexual  organs.  New  brides  fre- 
quently are  constipated  from  the  same  cause.  Close,  persistant 
attention  to  the  circulation  is  called  for  in  diagnosing  and 
treating  constipation,  as  one  of  its  most  important  factors.  Ev- 
ery etiological  factor  should  be  sought  out  and  all  properly  put 
together  in  order  to  spell  "constipation,"  as  it  is  in  this  indi- 
vidual. A  deficient  heptic  or  pancreatic  secretion  may  with- 
draw the  normal  excitement  from  the  ganglia  and  result  in 
constipation.  A  very  frequent  cause  of  constipation  is  catarrh 


586  ORIFIG1AL   SURGERY. 

of  the  mucous  coat  of  the  colon,  pointing  to  the  secretory 
nerves,  also  the  motor.  Here  we  frequently  find  diarrhea  and 
constipation  alternating.  A  small  fissure  may  induce  constipa- 
tion by  checking  the  regular  habit  of  going  to  stool. 

Habit  is  often  a  prominent  element  in  the  etiological  basis. 
Excessive  mental  work  and  deficient  physical  activity  should 
not  escape  our  scrutiny.  Irregular  habits  of  eating,  work  or 
sleep  must  be  looked  after,  the  general  health  and  conditions 
of  mind  not  neglected.  The  neurasthenic,  hysteric,  neurotic, 
idiotic  are  troubled  usually  with  constipation. 

Diet  is  next  to  blood  as  an  influence  in  regulating  the 
bowels.  It  may  often  cause  or  cure  this  common  complaint. 

In  regard  to  treatment  it  is  near  impossible  to  give  a  line 
of  treatment  as  each  case  must  be  treated  to  meet  the  indica- 
tions. The  treatment  must  be  based  on  the  etiology  which  re- 
quires the  finest  talent  to  diagnose.  Orificial  treatment  will 
nearly  always  be  called  for,  but  must  be  followed  by  judicious 
after-treatment.  Colonic  flushings,  medicated  or  plain,  re- 
peated dilatation,  proper  medication,  correct  habits  and  food 
must  all  receive  attention.  Massage,  electricity  and  proper  ex- 
ercise are  useful  in  many  cases.  A  regular  hour  for  stool  is  of 
great  importance.  Plenty  of  water  at  stated  intervals  is  of 
much  value.  Constipation  can  be  cured. 

CHAPTER  LXXVIII. 


EPILEPSY   TREATED   ORIPICIALL.Y 


EUG.    HUBBELL,    M.    D. 


In  presenting  this  paper  to  the  association,  it  is  not  to  set 
forth  an  array  of  successes  in  the  treatment  of  the  perplexing 
disease,  "epilepsy;"  but  to  report,  as  well,  my  failures,  believ- 
ing it  is  a  duty  we  owe  to  each  other  to  report  our  failures  as 
well  as  our  successes  and  hoping  that  others  may  make  similar 
reports  on  the  result  of  orificial  methods  in  the  treatment  of 
this  disease  so  that  in  the  near  future  statistics  can  be  prepared 


ORIFIGTAL   SURGERY.  587 

giving  an  accurate  percentage  of  epilepsies  cured,  and  also  the 
forms  that  are  most  amenable  to  orificial  methods.  Some  cures 
have  been  reported,  but  we  are  lacking  in  sufficient  data  to  es- 
tablish beyond  doubt  its  efficiency.  The  accumulated  work  of 
this  association  should  form  very  reliable  data,  if  it  could  be 
collected.  While  my  work  has  been  limited  I  hope  that  others 
will  be  influenced  to  make  more  complete  and  extended  reports. 

The  first  case  under  consideration  occurred  seven  years 
ago,  while  the  others  have  been  within  the  past  two  years. 

Case  1.  B.  G.,  has  had  epileptic  seizures  since  three 
months  of  age.  Nervous  ancestry  on  father's  side,  but  no  epi- 
lepsy. When  one  month  of  age  nurse  used  glass  syringe  to  give 
enema,  which  caused  much  screaming  and  hemorrhage  from 
rectum,  examination  showed  the  point  of  syringe  was  broken. 
When  I  first  saw  him  would  have  two  to  four  attacks  a  day, 
then  go  two  or  three  days  without  any,  had  all  the  charac- 
teristics of  epilepsy.  He  was  first  relieved  of  twenty-three  feet 
of  tape-worm,  but  this  had  but  little  if  any  effect  on  the  epi- 
lepsy though  it  improved  his  stomach  troubles.  Examination 
revealed  a  large  rectal  ulcer,  genital  organs  about  normal  as 
he  had  been  properly  circumcised  and  dilated;  cleansing  and 
cauterizing  ulcer  caused  severe  nervous  condition  to  super- 
vene, followed  by  one  of  his  seizures.  The  second  treatment 
caused  the  same  results,  but  he  went  a  whole  month  afterward 
without  an  attack,  parents  would  not  allow  any  more  treat- 
ments and  soon  moved  away  and  I  lost  sight  of  the  case.  Re- 
sult, not  cured.  Probable  cause,  the  rectal  ulcer. 

Case  2.  S.  P.,  male,  Oct.  29.  Has  clear  history.  Eight 
arm  atrophied  from  injury  at  seven  months  of  age.  Epilepsy 
appeared  at  age  of  twelve.  As  a  boy  used  tobacco,  smoked 
cigarettes  and  masturbated  to  excess.  Seizures  every  two  to 
four  weeks,  very  severe,  causing  great  prostration  for  one  or 
two  days. 

Pockets  and  papillae  removed  by  slit  operation,  using  co- 
caine. Urethra  dilated  once  every  two  to  four  weeks.  Sig- 
moid  strictures  were  overcome  by  the  sigmoid  sound,  and  gal- 
vanism was  used  twice  a  week  for  two  months,  then  once  in  a 
week  or  two.  The  attacks  grew  less  severe  and  further  apart 


588  ORIFICTAL   SURGERY. 

until  the  last  attack  was  very  light  and  after  an  exemption  of 
sixteen  weeks.  He  is  still  under  treatment.  Remedies  given 
were  nux  vomica,  eicuta,  sulphur  and  ananthe  at  different  in- 
tervals. Result,  greatly  improved. 

Case  3.  Mrs.  W.,  family  history  very  obscure.  Has  had 
severe  epileptic  attacks  for  four  years.  Had  two  or  three  mis- 
carriages, and  probably  illegitimate  child  at  term  as  examina- 
tion revealed  endometritis,  cervical  and  perineal  laceration, 
hemorrhoids,  pockets,  etc.  All-round  work  was  done,  under 
chloroform  anesthesia.  Had  one  attack  at  next  menstrual  pe- 
riod but  none  since  then  (Feb.  '96.)  Had 'some  after-treat- 
ments. Result,  apparently  cured. 

Case  4.  W.  W.,  boy  seven  years  old,  stout,  robust,  full- 
blooded,  thick  pouting  lips,  ferocious  appetite,  passes  restless 
nights,  starts  in  his  sleep  and  has  enuresis.  Began  to  have  epi- 
leptic attacks  when  three  years  of  age,  mother  is  a  sufferer 
from  the  disease.  Examination  revealed  enlongated  prepuce, 
narrow  meatus,  contracted  sphincters,  pockets  and  papillae.  All- 
round  work  was  done  last  January.  Symptoms  rather  aggra- 
vated for  two  or  three  weeks  then  slight  improvement.  In  May 
again  passed  sounds  and  dilated  rectum,  followed  by  aggrava- 
tion. Then  he  began  to  improve  again,  but  he  still  has  the 
attacks  once  a  week  but  not  so  severe  and  of  shorter  dura- 
tion. Has  taken  cina  followed  by  bellodonna.  Results, 
about  nil. 

Case  5.  Mrs.  W.,  aet  44.  Mother  of  four  children,  has  suf- 
fered from  epileptic  attacks  since  birth  of  her  first  child,  who 
is  now  fourteen  years  of  age.  Is  the  mother  of  Case  4  with 
good  family  history.  Has  two  or  three  attacks  per  month.  Ex- 
amination disclosed  endocervicitis,  retroflexion,  bilateral  lacer- 
ation of  cervix  and  severe  hemorrhoidal  condition  of  rectum. 
All-round  work  was  done,  including  the  American  operation. 
Was  up  in  three  weeks,  but  had  severe  nerve  storms  and  one 
epileptic  seizure  during  this  time,  since  which  time  she  has  had 
no  return  of  them  and  has  improved  in  general  health.  Of  the 
five  cases  here,  two  are  relieved,  one  nearly  so,  and  two  not 
benefited  or  only  slightly  so. 


ORIFIC1AL   SUEGEEY.  589 

The  President:  What  is  your  pleasure  with  Dr.  Hubbell's 
paper? 

Dr.  Means :  I  am  glad  to  know  that  the  doctor  wanted  to 
have  the  case  he  failed  in  known,  as  well  as  those  he  succeeded 
in.  With  epilepsy  I  have  not  been  successful.  I  have  succeed- 
ed in  curing  the  spasm  in  children  by  circumcision  alone.  I  had 
an  experience  which  I  shall  relate  with  reference  to  epilepsy.  A 
young  man  a  year  ago  applied  for  relief.  I  did  everything  be- 
fore I  tried  dilatation ;  and  after  I  used  dilatation  of  the  ureth- 
ra and  rectum  he  had  two  spasms,  where  before  he  had  one.  It 
continued  that  way;  I  operated  three  times,  and  every  time 
there  were  double  the  number  of  spasms  there  were  before.  I 
quit.  I  could  see  no  reason  why  it  did  so,  but  that  was  the 
result. 

Dr.  Dunn:  I  have  had  just  about  the  same  experience 
with  regard  to  epilepsy.  A  young  man,  a  student,  a  man  of 
rather  studious  habits,  was  taken  with  epilepsy  and  had  to 
leave  college.  Found  him  with  a  long  prepuce,  an  irritated 
rectum,  papillas,  and  stricture  of  the  urethra ;  gave  him  orificial 
treatment ;  removed  the  papillas  and  pockets  from  the  rectum ; 
dilated  the  urethra ;  made  a  thorough  dilatation  of  the  urethra 
and  did  everything  that  I  thought  would  relieve  the  tension 
upon  his  nervous  system,  but  the  result  was  not  satisfactory. 
His  convulsions  occurred  a  little  more  frequently  than  they 
did  before,  and  are  continuing  up  to  this  date.  I  have  been 
watching  this  case  to  find  what  I  have  overlooked.  In  all 
probability  this  epileptic  condition  is  very  different  from  the 
spasms  of  children  who  are  suffering  from  phimosis,  and  those 
cases  cannot  really  be  called  epilepsy.  I  think  those  cases  that 
are  epileptic  originate  in  the  ventricle  of  the  brain;  brain  trou- 
ble, and  orificial  work  is  not  going  to  remedy  the  difficulty — 
that  is  my  experience  with  this  epilepsy.  Yet  I  take  a  case  of 
epilepsy  in  hand  every  time  I  have  it,  and  treat  it  with  the  ex- 
pectation of  curing  it,  if  I  can  relieve  the  peripheral  irritation ; 
but  when  it  is  central  I  haven't  any  hopes  of  relief. 

Dr.  Notrebe :  The  first  case  of  epilepsy  I  treated  was  a 
young  lady  of  stout  build,  about  24  or  25  years  old,  who  had 
epilepsy  for  several  years.  She  did  not  seem  to  be  a  nervous 


590  OKIFIG1AL   SUEGEKY. 

case ;  she  could  control  herself,  and  was  in  good  physical  condi- 
tion. Like  the  doctor  who  has  just  spoken,  I  had  thought 
epilepsy  was  due  to  a  brain  lesion,  and  began  to  study  it  along 
that  line,  at  the  same  time  using  orificial  principles  to  see  if  I 
could  break  it  down.  On  examining  this  young  lady  I  found  a 
very  irritable  hymen,  clitoris  bound  down,  endometritis  and  re- 
troverted  uterus.  After  the  operation  she  had  continued  spells 
of  epilepsy,  and  I  think  they  lasted  twenty-four  to  forty-eight 
hours ;  she  would  not  be  free  from  them  more  than  half  an  hour 
at  a  time,  and  I  began  to  be  alarmed ;  I  thought  she  was  going 
to  die  of  epilepsy.  I  gave  her  morphine  and  applied  fomenta- 
tions, and  about  the  third  day  she  became  perfectly  quiet  and 
relieved,  and  did  well  until  the  stitches — and  I  was  just  think- 
ing of  that  case  as  the  doctor  was  reporting  his  knots — those 
knots  began  to  irritate  the  labia,  and  she  went  into  those  spells 
again,  which  became  almost  continuous  for  hours.  When  she 
came  out  I  asked  what  was  the  trouble,  and  she  said  something 
was  hurting  her ;  I  removed  those  knots,  applied  fomentations, 
and  she  immediately  became  better.  This  case  improved  and 
had  no  more  spells  for  months.  I  wasn't  satisfied,  and  I  made 
another  examination ;  in  examining,  I  irritated  the  rectum,  and 
she  had  more  spells.  I  found  there  were  some  pockets,  so  put 
here  on  the  table  and  removed  them.  I  think  the  case  has  been 
well  since  a  year  ago.  I  thought  then  that  all  cases  could  be 
cured. 

A  case  was  brought  to  me  that  had  had  epilepsy  for  fif- 
teen years,  and  would  have  from  fifteen  to  thirty  attacks  a 
day,  having  them  almost  every  day,  of  course  sometimes  not 
so  severe.  I  operated  and  found  the  same  conditions  as  in  the 
other  case,  and  did  about  the  same  work.  She  was  at  this  time 
an  imbecile.  Her  mind  improved  much,  and  the  epileptic  spells 
became  better  for  three  or  four  months,  but  she  had  a  retro- 
verted  uterus  that  I  couldn't  replace — it  wouldn't  stay  re- 
placed any  length  of  time.  When  Dr.  Pratt  was  in  Springfield 
he  operated  on  her,  and  removed  the  uterus  and  ovaries.  She 
has  gained  fifteen  ar  twenty  pounds  in  the  last  three  or  four 
months.  Her  mind  is  good.  She  now  does  all  the  work  at  home 


ORIFIG1AL   SURGERY.  591 

and  goes  everywhere  in  town  that  she  likes.  She  has  what 
she  calls  "sitting-down  spells,"  probably  once  a  week,  gets  up 
dazed,  but  goes  on  about  her  business.  This  case  is  much  im- 
proved in  mind;  the  greatest  improvement  is  in  the 
mind,  and,  considering  the  frequency  of  the  attacks 
in  the  beginning  and  her  condition  now,  she  is  wonderfully  im- 
proved, but  I  don't  consider  her  cured,  from  the  simple  fact 
that  I  believe  the  lesion  is  not  in  the  brain,  but  a  brain  train- 
ing, and  I  don't  believe  that  case  will  ever  be  cured,  if  she 
is  turned  loose  to  those  old  impressions.  I  can  bring  her  into 
a  company  of  people  and  the  excitement  will  bring  on  a  spell ; 
I  can  keep  her  confidence,  and  still  be  in  company,  and  these 
spells  will  not  occur.  I  have  come  to  the  conclusion  that  there 
is  a  brain  training,  and  unless  that  is  overcome  they  can't  be 
cured;  I  think  they're  like  drunkards — they  can't  get  over  it 
all  at  once ;  they  must  be  guided  and  developed,  but  I  believe 
they  can  be  cured. 

CHAPTER  LXXIX. 


TREATMENT  OP  ACNE  SIMPLEX  IN  YOUNG  MEN. 


H.    E.    BEEBE,    M.    D. 


ACNE,  ACNE  VULGARIS,  ACNE  DISSEMINATA. 


Acne  simplex  is  generally  regarded  as  a  chronic  idiopathic 
inflammation  of  the  sebaceous  glands,  in  the  center  of  which  is 
a  black  comedo  plug  or  a  pustule.  It  is  frequently  compli- 
cated with  other  affections  of  the  sebaceous  glands,  and  is  re- 
garded as  a  very  annoying  cutaneous  disease  especially  when 
it  appears,  as  it  commonly  does,  on  the  face. 

Much  is  written  concerning  its  pathology,  causes  and  treat- 
ment, yet  it  seems  to  be  understood  the  curative  treatment  has 
been  unsatisfactory.  There  is  an  artificial  acne,  due  to  the 
external  or  internal  influence  of  drugs — this  is  not  here  con- 
sidered. 


592  OBIFIC1AL   SURGERY. 

The  causes  usually  recognized  for  idiopathic  acne  are 
chronic  digestive  disturbances,  anemic  and  chlorotic  conditions 
and  sexual  disorders.  It  is  the  latter  cause  and  this  cause  as  a 
basis  for  suitable  treatment  that  is  here  emphasized.  This,  as 
a  cause,  until  quite  recently,  has  not  been  sufficiently  studied. 

Acne  simplex  occurs  chiefly  during  and  after  puberty, 
from  the  fourteenth  to  the  thirtieth  year.  It  is  confined  to 
both  sexes.  The  fact  that  its  occurrence  at  the  time  of  puberty 
is  most  common  with  those  addicted  to  sexual  weaknesses  and 
abuses,  and  that  it  often  appears  only  during  pregnancy,  or 
ceases  during  that  period,  and  that  eunuchs  are  very  rarely 
subject  to  it  is  proof  that  it  has  some  connection  with  the 
genital  sphere. 

That  it  can  be  easily  cured  by  proper  treatment  in  this  di- 
rection is  another  proof.  This  center  in  the  male  is  in  the  pro- 
static  inch  of  the  urethra ;  in  the  female  in  the  uterine  cervix. 
In  the  large  majority  of  cases  of  acne  simplex,  chronic  conges- 
tion can  be  found  in  this  locality,  and  proper  local  treatment 
of  this  center  in  addition  to  suitable  constitutional  remedies 
will  cure  most  cases  of  this  intractable  malady.  The  experience 
has  been  mostly  with  the  male  sex,  yet  there  is  no  reason  why 
the  opposite  sex  will  not  respond  equally  well  to  the  treatment. 
Where  formerly  treatment  was  futile,  during  the  past  two  years 
the  same  cases  of  years'  standing  have  been  cured. 

The  local  treatment  consists  in  the  systematic  use  of  steel 
sounds  to  overcome  the  irritation  almost  invariably  found  at 
the  prostatic  inch  of  the  urethra.  In  the  application  of  these 
sounds,  always  use  them  sufficiently  large  to  fully  distend  the 
entire  urethral  canal.  If  sounds  of  this  size  are  used  and  the 
circular  muscular  fibres  of  the  urethra  are  thoroughly  dilated, 
you  will  need  have  little  fear  of  the  much  talked  of  urethral 
fever.  When  this  does  follow,  it  is  certainly  due  to  the  use  of 
too  small  sounds  or  traumatiam  from  careless  manipulation. 

The  same  rules  will  apply  to  dilating  the  uterine  cervix.  If 
the  circular  fibres  of  the  cervix  be  fully  paralyzed  thereby  giv- 
ing free  vent  to  all  discharges,  little  danger  need  be  feared. 
To  overcome  this  local  congestion  these  sounds  should  be  used 


ORIFIC1AL    SURGERY.  593 

as  often  as  practicable  without  producing  traumatic  irritation. 
No  stereotyped  rule  can  be  given  for  this.  Each  case  must  be 
judged  according  to  the  irritation  present. 

It  is  astonishing  what  marked  improvement  is  observed  in 
the  acne  in  most  cases  in  a  few  weeks,  no  matter  how  chronic 
the  case  be,  certainly  proving  that  it  is  reflex  in  its  origin.  It 
is  a  line  of  treatment  that  cannot  help  but  convince  the  most 
skeptical,  for  it  is  certainly  calculated  to  cure  the  majority  of 
these  cases  when  systematically  followed. 

CHAPTER  LXXX. 


SYMPATHETIC  VOMITING. 


W.   H.   HURT.   M.   D. 


To  show  the  power  that  orificial  surgery  has  in  cases  of 
vertigo,  nausea  and  vomiting  associated  with  fomale  diseases, 
I  will  cite  two  cases: 

Mrs.  C.,  aged  22.  For  the  last  six  months  has  felt  mis- 
erable and  for  the  last  two  months  compelled  to  keep  her  bed 
most  of  the  time.  If  she  gets  up  and  walks  about  becomes  very 
dizzy  and  wants  to  vomit.  The  nausea  and  vomiting  with  ver- 
tigo is  brought  on  at  once,  as  soon  as  she  tries  to  ride  in  any 
vehicle.  Has  sick  headache  once  or  twice  a  week,  affecting 
the  left  side  of  the  head.  No  appetite ;  bowels  obstinately  con- 
stipated ;  cannot  have  a  passage  from  the  bowels  without  tak- 
ing a  cathartic ;  so  weak  can  hardly  walk.  At  every  menstrual 
period  suffers  intensely  during  the  whole  period  and  flows  but 
little.  An  examination  of  the  rectum  showed  it  extremely  sensi- 
tive, much  inflamed,  with  three  large  pockets  and  three  papillae. 
The  cervix  utri  inflamed  and  a  greatly  constricted  os.  The 
left  ovary  sensitive  on  pressure  and  pains  her  much  at  the  men- 
strual period. 

Operation :  Assisted  by  Dr.  W.  M.  Johnson,  the  patient 
was  put  under  chloroform,  and  the  rectum  thoroughly  dilated, 
the  papillae  removed,  the  pockets  curetted  and  the  bowel  thor- 


594  ORIFIC1AL    SURGERY. 

oughly  flushed  with  carbolized  hot  water.  The  cervix  uteri 
dilated  with  sounds  up  to  No.  27  English  scale,  then  curetted 
the  whole  inside  of  the  uterus,  using  Dr.  F.  D.  Ilolbrook's  cu- 
rette which  washes  away  the  debris  as  fast  as  it  is  removed 
from  the  surface. 

The  recovery  in  this  case  was  something  marvelous;  the 
next  day  she  was  greatly  improved,  and  in  one  week  a  well 
woman.  Her  vertigo,  nausea  and  vomiting  had  all  gone,  and 
her  bowels  moved  every  day  perfectly  natural,  something  they 
had  not  done  in  six  months  without  being  forced  by  the  use  of 
cathartics. 

March  8,  1894.  Mrs.  II.,  aged  28  years,  mother  of  one 
child  three  years  old.  Always  a  healthy  woman  until  the  birth 
of  her  child;  has  not  been  well  since.  The  right  ovary  has 
pained  her  almost  daily,  and  has  a  continued  heavy  bearing- 
down  pain  in  the  region  of  the  womb,  with  constant  leucor- 
rhea.  For  the  last  eight  months  has  had  nausea  and  vomiting 
of  a  very  obstinate  nature ;  has  vomited  every  day  and  most  of 
the  time  as  often  as  every  hour ;  has  been  compelled  to  keep  her 
bed  for  months.  Has  had  seven  different  physicians.  All  have 
diagnosed  pregnancy  and  treated  her  without  the  least  bene- 
fit. An  examination  of  the  uterus  found  it  greatly  enlarged 
and  not  pregnant,  but  a  well  marked  case  of  subinvolution. 
The  rectum  was  extremely  sensitive  and  filled  with  hemor- 
rhoids. 

Operation:  Assisted  by  Dr.  W.  M.  Johnson,  who,  by  the 
way,  confirmed  my  diagnosis  that  it  was  a  marked  case  of  sub- 
involution  of  the  womb  associated  with  a  very  irritable  rectum. 
After  the  patient  was  anesthetized  the  womb  was  dilated  with 
the  Pratt  sounds  up  to  No.  27,  curetted  most  thoroughly  and 
washed  out  with  carbolized  water.  The  rectum  was  dilated 
and  five  large  hemorrhoids  removed,  and  then  well  flushed  with 
the  carbolized  water.  I  am  satisfied  that  I  get  much  better 
results  in  these  cases  where  a  large  quantity  of  carbolized  water 
is  used  during  and  after  the  operation,  than  can  be  had  where 
the  simple  dry  absorbent  cotton  is  used. 

The  effect  of  this  operation  on  this  poor  afflicted  woman 
was  something  to  be  proud  of.  The  next  day  she  felt  like  a 


ORIFIC1AL    SURGERY.  595 

new  being  and  in  ten  days  was  up  and  doing  her  house-work, 
feeling  absolutely  well,  but  still  weak.  She  was  kept  on  dia- 
lyzed  iron,  ten  drops  ter  die  for  four  weeks,  then  discharged 
cured.  She  never  vomited  once  after  the  operation,  although 
the  last  thing  she  did  before  taking  the  chloroform  was  to 
vomit. 

CHAPTER  LXXXI. 


HICCOUGH  CURED. 


E.   H.   PRATT,   M.   D. 


Mrs.  T.  was  about  42  years  of  age  and  in  fairly  good  gen- 
eral health,  being  one  of  those  strong  wiry  natures  that  seem 
able  to  exhibit  almost  any  amount  of  endurance  when  called 
upon  to  do  so — a  good  subject  for  tetanus  or  epilepsy.  Her 
distress  was  hiccough. 

When  she  applied  for  relief  she  had  been  suffering  for  two 
weeks,  growing  steadily  worse.  In  that  two  weeks  she  had 
made  diligent  search  for  relief  elsewhere,  first  to  the  drug- 
stores in  her  neighborhood  and  the  doctors  they  recommended, 
from  all  of  which  she  obtained  neither  relief  nor  encourage- 
ment. In  her  desperation,  although  she  was  a  woman  of  some 
means,  not  knowing  what  else  to  do,  she  made  application  for 
admission  to  Cook  County  Hospital  under  the  impression  that 
some  of  the  attending  men  in  that  great  place  might  be  able  to 
handle  her  case  successfully.  In  that  institution,  however,  she 
got  no  further  than  the  examining  room.  She  was  told  that 
her  case  was  perfectly  incurable,  and  she  might  as  well  pre- 
pare to  die.  They  informed  her  that  Cook  County  Hospital 
was  an  emergency  hospital,  and  for  curable  cases  only ;  that  in- 
curable cases  were  sent  out  to  Jefferson  to  the  poorhouse,  and 
if  she  wished  they  would  issue  an  order  for  her  admission  to 
that  institution,  remarking  at  the  same  time  that-  her  stay 
there  would  not  be  long,  as  hiccough  was  always  fatal  and  she 
would  not  have  long  to  remain  anywhere.  She  thanked  the 


596  ORIFIG1AL   SURGERY. 

interne  who  examined  her  for  his  kindness  and  his  opinion, 
said  that  she  had  car  fare  enough  to  get  home  with,  and  if  she 
was  going  to  die  she  wouM  rather  die  at  home  than  in  the 
poorhouse. 

As  Cook  County  Hospital  had  failed  her,  she  decided  to 
visit  the  medical  colleges  in  the  neighborhood  and  persevere  in 
her  search  until  some  one  was  found  who  took  a  more  hopeful 
view  of  her  case.  In  pursuance  of  this  resolution  she  came  first 
to  our  clinic  and  was  referred  to  the  orificial  chair.  When 
she  presented  herself  for  examination  the  habit  of  hiccough 
was  badly  established  and  accompanied  with  severe  general 
convulsive  movements  of  her  entire  body.  Although  she  had 
applied  as  a  clinical  patient  she  refused  to  be  made  a  clinic  of, 
and  insisted  upon  the  work  being  done  at  her  own  home.  As 
no  time  was  to  be  lost,  the  next  day  she  was  placed  under  an 
anesthetic  and  subjected  to  general  orificial  work,  which  con- 
sisted in  loosening  of  the  hood  of  the  clitoris,  repairing  a  badly 
lacerated  cervix,  and  in  performing  slit  work  upon  the  rectum. 
It  should  be  stated  that  the  laceration  of  the  cervix  was  an 
unusual  one,  presenting  a  three-cornered  tear,  the  tissues  be- 
tween the  tears  being  hypertrophied  and  very  much  hardened, 
so  much  so  as  to  suggest  a  tendency  to  carcinomatous  degenera- 
tion. The  lining  of  the  vagina  was  pale  and  leathery.  One  of 
the  lacerations  proved  to  be  very  deep,  and  the  cicatricial  scar 
extended  for  some  distance  into  the  body  of  the  uterus.  The 
cicatricial  tissue,  however,  was  all  carefully  removed  and  the 
parts  of  the  cervix  carefully  readjusted  and  restored  to  a 
proper  shape.  In  the  rectum  there  were  a  few  small  papilla? 
and  an  unusual  number  of  rectal  pockets,  having  also  a  few 
very  small  hemorrhoids.  The  anal  orifice  was  badly  con- 
tracted and  there  was  evidence  of  rectal  catarrh. 

The  anesthetic  employed  was  chloroform,  to  the  adminis- 
tration of  which  she  yielded  very  reluctantly,  requiring  dou- 
ble the  amount  usually  needed  for  anesthesia  and  taking  twice 
as  long  as  common  to  succumb  to  its  effects.  Further  than 
this,  however,  her  case  presented  no  difficulties  whatever,  and 
proved  to  be  eminently  satisfactory  in  every  respect.  She  went 
to  sleep  with  the  hiccough  and  awoke  without  it,  and  although 


ORIFIC1AL   SURGERY.  597 

nearly  two  months  have  elapsed  since  the  operation,  it  has 
never  put  in  an  appearance.  She  already  complains  of  feel- 
ing better  than  she  has  in  twenty  years,  and  is  deeply  grateful 
for  her  rescue. 

Cases  of  pernicious  hiccough  are  so  rare  that  it  seemed 
important  to  place  this  one  on  record,  as  it  was  so  eminently 
successful  and  bears  marked  testimony  to  the  wonderful  power 
of  orificial  work  in  such  cases,  and  also  gives  silent  testimony 
of  the  ignorance  of  the  medical  profession  generally  of  one  of 
the  most  powerful  agents  for  correcting  functional  disorders 
at  the  command  of  the  medical  profession.  Just  because  the 
woman's  entire  distress  seemed  to  be  hiccough,  none  of  the 
doctors  or  druggists  to  whom  she  applied  for  relief,  not  even 
the  interne  who  had  charge  of  the  examining  room  of  Cook 
County  Hospital,  thought  far  enough  to  consider  it  possible 
that  some  pelvic  trouble  might  furnish  a  satisfactory  explana- 
tion for  the  existence  of  the  dread  disease  known  as  malig- 
nant hiccough.  And  yet  this  is  such  a  reasonable  explanation. 
Every  doctor  who  has  ever  had  to  do  with  pregnant  women 
knows  of  the  intimate  relationship  between  the  uterus  and  the 
stomach,  for  the  great  majority  of  pregnant  women  are  trou- 
bled with  morning  sickness  during  the  first  three  months  of 
pregnancy,  when  it  is  commonly  recognized  that  the  stomach 
has  nothing  to  do  with  its  own  distress,  but  is  suffering  from 
an  irritable  condition  of  the  pelvic  organs.  The  close  relation- 
ship between  the  phrenic  and  pneumogastric  nerves  and  the 
sympathetic  nerve  was  also  completely  ignored  by  those  who 
had  the  opportunity  of  examining  the  case,  so  that  not  even 
rectal  troubles  were  thought  of  as  responsible  for  the  fatal 
malady.  Indeed  not  a  druggist  or  doctor  with  whom  she  came 
in  contact  in  her  whole  two  weeks'  search  for  relief  even 
thought  of,  or  at  least  suggested,  an  examination  of  the  pelvic 
organs  with  the  view  of  ascertaining  their  condition,  but  sim- 
ply recognized  that  hiccough  was  a  fatal  trouble,  and  told  the 
woman  that  her  end  was  near,  and  that  nothing  could  be  done 
for  her,  acknowledging  themselves  perfectly  helpless  to  com- 
bat the  formidable  condition  in  which  she  presented  herself. 
It  is  with  no  small  degree  of  satisfaction  to  me,  however,  that 


598  ORIFIC1AL   SURGERY. 

the  interne  of  the  institution  to  which  she  applied  remembered 
his  orificial  teachings  and  was  thoughtful  enough  to  give  the 
woman  the  orificial  straw  to  grasp  at,  and  that  she  embraced 
this  only  opportunity  which  had  been  extended  to  her,  and  has 
the  satisfaction  of  securing  for  her  trust  and  confidence  the 
restoration  to  health  which  she  was  seeking. 

Orificial  work  has  scored  thousands  of  professional  tri- 
umphs of  which  it  can  well  be  proud,  but  it  is  seldom  that  it 
has  scored  one  more  brilliant  and  encouraging  than  it  accom- 
plished in  this  case  of  pernicious  hiccough. 


SECTION  X. 


Miscellaneous, 


V 


ORIFIC1AL    SURGERY.  601 


CHAPTER  LXXXII. 


SEXUAL  HABITS  AND  NECESSITIES. 


E.    H.    PRATT,    M.    D. 


Humanity  is  naked,  therefore  it  is  clothed.  It  is  shame- 
faced, and  hence  struts  about  in  assumptions  of  false  pride  and 
dignity.  Only  a  limited  number  of  the  organs  of  the  body  and 
a  corresponding  number  of  their  diseases  are  recognized  and 
considered  fit  subjects  for  public  consideration.  It  is  needless 
to  remark  as  a  comment  upon  this  state  of  things  that  the  un- 
cleanliness  is  not  on  the  part  of  the  body  or  its  diseases,  but 
lies  in  the  unworthy  conception  of  the  observer. 

Sexual  organs  and  rectums  were  constructed  by  the  same 
God  that  made  eyes,  ears,  noses  and  throats,  and  the  human 
being  that  sees  dirt  in  the  study  of  any  of  God's  works  is  sim- 
ply vulgar  and  is  an  unfit  condition  for  scientific  investigation. 
Love  is  ever  respectable ;  lust  is  never  so.  Sexuality  is  always 
a  proper  subject  for  consideration;  sensuality  needs  a  doctor. 
Sick  hands  and  feet,  livers  and  stomachs,  brains  and  lungs,  and 
bones  and  spinal  cords  have  received  due  consideration  at  the 
hands  of  the  medical  fraternity,  but  sick  sexual  organs  and 
rectal  conditions  which  have  long  needed  a  doctor  have  been 
seriously  neglected. 

The  establishment  of  the  orificial  philosophy  will  correct 
this  unkindness  and  disrespect  to  humanity  and  its  God,  and 
the  parts  which  for  centuries  have  been  festering  under  the 
fig-leaf  will  receive  the  consideration  of  which  they  have  long 
stood  in  need,  and  the  prospects  for  the  cure  of  lust  which 
through  all  history  has  been  sapping  the  vitality  of  humanity 
are  brightening.  The  fact  that  what  we  now  know  as  merely 
manifestations  of  ill  health  have  been  heretofore  known  as 
sins  needs  to  be  universally  recognized.  The  tendency  to  the 
violation  of  laws,  mental,  moral,  physical  or  spiritual,  is  not  a 
natural  one  and  only  occurs  when  something  is  wrong. 

JLLIEG 


602  ORIFIC1AL    SURGERY. 

While  each  organ  of  the  body  has  its  separate  functions  to 
perform,  and  while  it  possesses  its  own  peculiar  characteristics 
personal  to  itself,  it  is  at  the  same  time  a  part  of  the  whole 
body,  partaking  of  its  weakness  and  of  its  strength,  its  sickness 
and  its  health,  its  joys  and  its  sorrows,  its  poverty  and  its 
prosperity,  its  virtues  and  its  vices,  its  integrity  and  its  dis- 
integration. Laws  of  growth,  development,  waste  and  repair, 
prevail  universally  throughout  the  body,  and  all  the  organs  are 
loyal  subjects  in  the  bodily  dominion.  A  healthy  human  body 
is  a  unity ;  it  is  entirely  unconscious  of  eyes  or  ears  or  hands  or 
other  organs.  Its  separate  parts  are  consecrated  to  the  use  of 
the  whole,  and  only  as  they  are  put  to  use  is  their  existence 
brought  into  prominence.  In  consequence  of  this  universal 
plan  of  existence,  whenever  an  organ  obtrudes  itself  in  an  un- 
called for  manner  upon  the  attention  of  the  individual,  it  loses 
its  harmonious  connection  with  the  whole,  and  something  is 
disturbing  it.  If  it  is  an  organ  presided  over  by  the  cerebro- 
spinal  system,  it  usually  manifests  its  disorderly  condition  by 
pain  or  its  absence.  It  is  liable  to  be  either  hyperesthetic  or 
anesthetic.  Eyes  become  sensitive  to  light  or  take  on  the  op- 
posite condition  and  become  insensitive  to  it,  staring  blindly  in- 
to daylight  as  though  it  were  night.  Ears  become  too  sensitive 
or  too  obtuse ;  and  in  a  similar  manner  all  the  cerebro-spinal 
family  report  the  individual  in  the  language  of  consciousness, 
and  call  for  a  doctor.  Where  the  disordered  organ  does  not 
disturb  bodily  sensations,  its  appearance  gives  evidence  of  its 
disordered  condition.  The  spot  involved  is  too  red  or  too  pale, 
is  too  hard  or  too  soft,  is  too  hot  or  too  cold,  is  too  swollen  or 
too  sunken.  The  parts  supplied  by  the  sympathetic  nerve, 
however,  when  they  are  in  trouble,  require  a  finer  diagnosti- 
cian to  appreciate  their  disordered  state,  and  a  better  doctor 
for  their  repair;  for  unless  they  enlist  the  sympathies  of  the 
cerebro-spinal  system  and  voice  their  troubles  vicariously,  the 
symptoms  of  their  illness  can  be  interpreted  only  in  the  lan- 
guage of  disturbed  functions,  and  their  repair  involves  not 
only  ordinary  medical  knowledge,  but  also  the  application  of 
a  good  deal  of  common  sense,  a  quality  entirely  too  little  em- 
ployed in  the  practice  of  the  healing  art. 


EIJ 


ORIFIC1AL   SURGERY.  603 

As  the  present  is  the  age  of  the  "new  woman"  for  the 
world  at  large,  in  our  doctor  world  it  can  and  will  be  called 
the  age  of  the  sympathetic,  for  now  that  it  is  at  last  beginning 
to  dawn  upon  the  medical  profession  that  reactive  power  and 
vitality  and  good  capillary  circulation  and  sympathetic  power 
are  synonymous  terms  the  sympathetic  nerve  and  its  functions 
are  being  investigated. 

Almost  every  nation  has  its  cult.  It  selects  its  hero,  and 
thousands  of  devotees  search  public  records  and  private  corre- 
spondence for  every  item  of  knowledge  that  can  be  obtained 
of  its  hero.  France  has  its  Napoleon  cult,  Germany  its  Bis- 
marck cult,  England  its  Gladstone  and  Shakespeare  cults, 
America  its  Washington  and  Lincoln  cults.  The  professions, 
too,  have  their  cults,  and  in  the  profession  of  medicine  the  com- 
ing cult,  not  only  for  the  present  time  but  for  all  time,  is  and 
will  be  the  sympathetic  nerve.  It  is  no  passing  fad,  and  no 
mere  fashionable  study  of  the  day;  its  importance  as  a  factor 
in  the  interpretation  and  cure  of  all  forms  of  human  ailments 
has  become  so  permanently  conspicuous  that  the  study  of  the 
sympathetic  nerve  can  never  again  be  neglected  as  it  has  been 
and  pass  into  obscurity.  The  plan  of  construction  by  which 
the  body  is  built  and  maintained  has  not  varied  since  its  cre- 
ation. All  men  in  all  ages  have  possessed  sympathetic  nerves 
and  sympathetic  nerve  force,  although  it  has  not  been  recog- 
nized as  the  physical  means  by  which  inspiration  flows  into  hu- 
manity, has  propelled  the  inhabitants  of  the  world  through  all 
their  coming  and  their  going,  through  all  their  pleasures  and 
through  all  their  crime,  through  all  their  backsliding  and 
through  all  their  evolutions.  But  this  silent  mainspring  of  life 
that  has  run  for  ages  the  machinery  of  every  human  form  that 
has  walked  the  earth  has  done  its  work  so  silently,  so  modestly, 
so  unpretentiously,  as  to  almost  have  escaped  observation,  per- 
mitting the  reputation  for  growth  and  for  repair,  for  health 
and  for  sickness,  for  deatli  and  for  longevity  to  be  ascribed  to 
other  portions  of  the  human  anatomy.  The  arrogant,  lordly, 
noisy,  presumptuous,  self-conscious  and  presuming  cerebro- 
spiual  system  has  received  not  only  its  mean  of  consideration 
and  appreciation,  but  has  appropriated  to  itself  much  of  the 


604  ORIFIG1AL   SURGERY. 

reputation  and  attention  that  has  rightfully  belonged  to  the 
gentler  and  less  obtrusive  sympathetic.  It  has  not  been  fully 
appreciated  until  the  last  decade,  indeed  is  not  even  now,  that 
upon  the  integrity  of  the  sympathetic  nerve  depends  the  ton- 
icity  and  nutrition  of  the  entire  body,  even  of  the  cerebro- 
spinal  system  itself.  The  result  of  this  misapprehension  of  the 
relative  importance  of  the  two  nervous  systems  in  matters  of 
nutrition  from  a  professional  standpoint  has  been  to  lead  the 
medical  profession  into  a  hare  and  hound  chase  after  the  ef- 
fects of  disorders  rather  than  point  them  to  their  causes.  That 
the  first  cause  of  chronic  diseases  of  all  kinds  is  a  lowering  of 
vitality  and  insufficient  reactive  power,  a  poor  circulation,  or 
what  is  the  same  thing  a  wasted  sympathetic  nerve  force  you 
and  I  well  know,  and  our  life  work  will  not  be  well  done  until 
the  entire  medical  profession  is  thoroughly  vaccinated  with 
the  thought,  so  that  it  can  never  again  ignore  the  important 
subject  of  waste  and  repair  of  the  sympathetic  nerve  in  the 
study  of  physical  ailments  and  their  remedies.  When  this  great 
truth  is  once  thoroughly  appreciated,  and  it  is  equally  under- 
stood that  the  entire  sexual  system  of  both  sexes  is  operated 
by  sympathetic  nerve  force,  the  sexual  habits  of  the  race  will 
be  subjected  to  a  thorough  and  scientific  scrutiny  that  they 
have  always  needed  and  never  received. 

The  part  which  lust  has  played  in  the  degenerate  changes 
of  the  human  body  has  been  amply  suggested  throughout  all 
the  ages,  and  by  those  who  are  wholly  ignorant  of  physical 
anatomy  and  physiology;  for  the  proverbial  fall  of  Adam  has 
been  universally  ascribed  by  priests  and  laymen  alike  to  a  fond- 
ness for  some  form  of  sexual  indulgence,  the  most  insidious 
and  generally  prevailing  one  being  that  of  lust.  Lustful  pro- 
pensities have  been  sufficiently  influential  in  the  history  of  man- 
kind to  vaccinate  the  entire  race  with  syphilis  and  its  inheri- 
tances, among  whch  may  be  classed  many  diseases  of  skin  and 
mucous  membrane,  brain  and  spinal  cord,  and  consumption  as 
its  descendants;  and  they  have  established  and  maintained  all 
the  houses  of  ill  fame,  have  fathered  all  illegitimate  children, 
have  been  responsible  for  the  abortion  business,  have  perpetu- 
ally ill-mated  humanity  and  in  many  cases  divorced  it,  have 


ORIFIGIAL    SURGERY.  605 

driven  women  to  wine  and  men  to  whiskey,  have,  indeed, 
caused  such  widespread  havoc  with  the  health  and  happiness 
of  mankind  that  it  is  difficult  to  say  what  form  of  physical, 
mental  and  moral  mischief  may  not  be  explained  by  them.  Be- 
cause the  extravagant  expenditure  of  sexual  power  is  painless, 
and  because  it  is  not  understood  that  this  same  power  is  the 
vital  force  by  which  men  and  women  live  and  work,  the  medi- 
cal profession  have  never  realized  that  the  responsibility  of 
purifying  the  lives  of  their  patrons  rested  with  them.  But 
the  time  has  now  come  when  these  catacombs  of  undermining 
lustful  propensities  are  to  be  explored  and  ventilated,  and  the 
great  mission  of  orificial  surgery  to  the  world  will  never  have 
been  accomplished  until  it  is  demonstrated  to  all  mankind  that 
the  eradication  of  sickness  from  the  face  of  the  earth  involves 
the  regeneration  of  its  inhabitants.  Lust  must  die  that  love 
may  live,  sensuality  must  give  place  to  sexuality,  and  man's 
animal  propensities  must  cease  their  domination  and  become 
servants  instead  of  masters.  In  effecting  this  emancipation  of 
the  race,  the  orificial  philosophy  and  its  methods  of  application 
are  necessities,  and  we  are  here  to  discuss  what  remedies  and 
what  plans  of  action  are  best  calculated  for  the  eradication  of 
sensuality.  The  cure  of  this  disease  is  not  merely  to  regulate 
it,  not  merely  to  establish  habits  of  outer  conduct,  but  to  de- 
stroy temptation  by  removing  all  lustful  tendencies. 

As  for  sexual  necessities,  in  an  ideal  state  of  humanity 
there  is  no  more  need  for  sexual  indulgence,  except  for  the 
propagation  of  the  species,  than  there  is  for  tears.  When  any 
organ,  when  its  use  is  not  demanded,  obtrudes  itself  upon  the 
consciousness  of  an  individual,  it  is  in  a  condition  of  irrita- 
blty  from  some  physcal  cause,  and  needs  to  be  doctored,  and 
the  sexual  system  is  no  exception  to  the  rule.  Sexual  indulg- 
ence is  necessary  for  the  propagation  of  the  species;  it  is  not 
necessary  for  either  the  health  or  happiness  of  the  individual. 
But  to  bear  this  message  to  mankind,  to  educate  men  and 
women  to  a  knowledge  and  practice  of  this  great  truth,  in 
other  words,  to  cure  the  world  of  lust  and  stop  the  great  nerve 
waste  which  throughout  all  generations  past  has  silently,  in- 
dustriously and  unnoticed,  enervated  the  human  race  and  per- 


60S  ORIFIC1AL    SURGERY. 

mitted  it  to  be  the  prey  of  the  varied  forms  of  physical  dis- 
orders known  as  chronic  diseases,  is  the  ultimate  goal  of  the 
orificial  thought;  and  although  the  journey  is  a  long  and  dif- 
ficult one,  it  is  time  we  set  out  on  our  way.  If  bed  sores  can 
be  cured  they  can  be  prevented;  and  if  orificial  surgery  can 
cure  the  offscourings  of  medical  practice,  the  asthmas  and 
rheumatisms  and  insanities  and  eczemas  and  dyspepsias  ;mtl 
consumptions  and  other  forms  of  previously  incurable  trou- 
bles, the  same  principles  applied  earlier  can  prevent  them. 
When  we  claim  that  orificial  surgery  can  cure  these  troubles 
we  are  not  presenting  the  subject  quite  fairly.  The  proper 
statement  of  the  case  would  be  that  orificial  surgery  can  ren- 
der their  cure  possible,  for  orificial  surgery  unaided  is  insuf- 
ficient for  the  great  work  in  which  it  is  so  helpful.  It  needs 
to  be  supplemented  by  every  other  helpful  measure  that  is 
available;  and  while  orificial  work  is  the  chief  factor  in  the 
remarkable  cures  which  we  are  all  making,  we  must  not  neglect 
to  give  proper  credit  to  the  other  measures,  which  we  by  no 
means  desire  to  underestimate.  Indeed,  it  is  to  some  of  these 
other  measures  I  desire  to  attract  your  attention  today.  It 
goes  without  saying  that  the  members  of  the  American  As- 
sociation of  Orificial  Surgeons  are  already  fully  alive  to  the 
necessity  for  applying  orificial  methods  to  all  cases  of  sexual 
abnormality.  But  after  this  has  been  accomplished,  either  by 
operation  or  treatment,  or  both,  what  next  for  those  cases  still 
remaining  uncured,  and  possibly  temporarily  aggravated  by 
the  work? 

DRUGS. 

The  emotional  sphere  of  drug  action  is  extensive.  Drugs 
are  serviceable  in  relieving  a  disposition  to  cry  or  to  laugh  or 
to  be  irritable ;  they  are  applicable  to  hallucinations  or  to  mel- 
ancholia ;  to  a  condition  of  fears  and  apprehensions,  as  if 
something  would  happen;  or  to  attacks  of  rage  or  to  ten- 
dencies to  murder  and  suicide.  They  are  equally  efficacious  in 
lascivious  tendencies.  They  can  take  away  the  appetite  for  to- 
bacco or  liquor,  and  also  take  away  the  appetite  for  women, 
or  propensities  to  masturbation.  Drugs  are  curative.  They  are 


ORIFIG1AL    SURGERY.  607 

invaluable  in  the  treatment  of  chronic  as  well  as  acute  cases, 
and  we  must  still  study  them. 

WATER. 

Water  judiciously  applied  is  one  of  the  most  helpful  of 
remedial  agents  in  re-establishing  physical,  mental  and  moral 
equilibrium.  In  chronic  cases  hot  water  is  seldom  needed  un- 
less the  patient  be  very  feeble,  and  its  use  is  needed  to  ensure  a 
proper  degree  of  reaction  after  the  employment  of  cold.  The 
most  useful  forms  of  applying  it  are  the  foot  bath,  sitz  bath, 
spinal  compress,  and  the  shower  bath  or  dip.  Cold  compresses, 
general  or  local,  are  also  serviceable  in  many  cases,  but  are 
more  difficult  of  application,  and  can  in  most  cases  be  dis- 
pensed with.  When  Father  Kneipp,  of  Bavaria,  issued  to  the 
world  his  first  book,  entitled,  "My  Water  Cure,"  he  conferred 
a  benefit  of  inestimable  value  upon  mankind.  The  world  has 
bathed  and  used  compresses  and  drank  water  from  the  infancy 
of  the  race,  but  the  value  of  its  scientific  application  in  the 
healing  of  the  sick  was  not  well  known.  How  hungry  the  world 
was  for  the  knowledge,  however,  is  evidenced  by  the  fact  that 
in  two  years'  time  the  aged  priest  was  compelled  to  issue  fifty 
editions  of  the  work,  six  thousand  in  an  edition,  making  a  sale 
of  over  three  hundred  thousand  copies  of  his  book  in  the  space 
of  two  years,  an  experience  entirely  unprecedented  in  medi- 
cine. Instead  of  consuming  your  valuable  time  today  in  the 
consideration  of  water  and  its  uses  for  professional  purposes, 
I  will  earnestly  recommend  every  member  of  the  association  to 
possess  themselves,  if  they  have  not  already  done  so,  of  a  copy 
of  Father  Kneipp 's  remarkable  production  and  make  use  of 
whatever  of  his  suggestions  may  strike  them  as  practical  and 
worthy  of  application.  The  practice  of  walking  barefooted  in 
the  wet  grass  for  ten  or  fifteen  minutes  every  morning,  putting 
on  the  stockings  and  shoes  without  drying  the  feet,  and  then 
take  a  brisk  walk  for  ten  or  fifteen  minutes  longer  for  those 
who  are  able  to  do  so,  and  who  are  so  situated  as  to  make  it 
possible,  is  not  only  a  pleasant  diversion,  but  has  a  wonderful 
effect  in  awakening  the  sleeping  energies  of  the  system  and  in 
relieving  internal  congestions  and  inflammations,  especially  of 


603  ORIFIC1AL    SURGERY. 

the  head  and  spine.  Those  who  from  any  cause  are  unable  to 
avail  themselves  of  this  suggestion  will  be  able  to  obtain  a 
similar  benefit  from  plunging  the  feet  in  a  pail  of  cold  water 
and  retaining  them  there  from  thirty  seconds  to  three  or  four 
minutes,  one  minute  usually  being  long  enough.  The  feet  are 
afterward  to  be  .clothed  with  stockings  and  shoes  and,  when 
reactive  power  is  poor,  each  foot  can  be  whirled  by  an  as- 
sistant, who  seizes  an  ankle  in  one  hand  and  the  toes  with  the 
other  and  thus  turns  them  in  a  circle,  revolving  each  foot  in 
the  neighborhood  of  150  times.  If  the  patient  is  unable  to 
walk  his  feet  should  be  warmly  covered  after  this  exercise  un- 
til reaction  has  become  fairly  established. 

The  spinal  compress  is  a  valuable  adjunct  not  only  in 
spinal  cord  and  brain  affections,  but  also  as  a  general  tonic 
where  increased  reactive  power  is  needed.  Its  tendency  is  to 
flush  the  capillaries,  acting  almost  as  quickly  and  surely  as 
rectal  dilatation.  In  making  use  of  the  compress,  take  a  towel 
folded  lengthwise  until  it  is  about  four  inches  in  width  and 
as  long  as  the  spine,  saturate  it  in  ice  water,  wring  it  out,  and 
apply  it  the  whole  length  of  the  spine.  It  is  then  to  be  cov- 
ered with  a  folded  sheet,  and  the  patient  turned  on  his  back 
and  made  to  lie  upon  it  for  half  or  three-quarters  of  an  hour. 
After  its  removal  the  patient  shall  still  lie  upon  the  back  for 
half  an  hour  longer,  until  the  back  is  warm.  The  ice  water  may 
be  medicated  with  salt  or  vinegar  or  arnica,  or  whatever  drug 
may  please  the  doctor.  These  drugs  are  absorbed  by  the  skin 
as  well  as  by  the  mucous  membrane,  and  whatever  drug  is 
called  for  can  be  used  with  advantage  in  connection  with  the 
compress.  If  the  patient  is  a  very  feeble  one,  it  is  often  well 
to  rub  the  spine  quickly  with  alcohol,  following  this  with  rub- 
bing before  putting  him  upon  his  back  again. 

A  pitcher  of  cold  water  poured  daily  over  the  external 
sexual  system  and  rectum  while  the  patient  is  placed  across 
the  operating  chair  and  protected  by  a  Kelly  apron  is  another 
exceedingly  valuable  measure.  A  dip  in  a  bath-tub  of  cold 
water,  or  a  shower,  should  not  be  taken  except  reaction  has 
been  ensured  by  either  a  hot  bath  or  a  sufficient  amount  of  ex- 
ercise taken  just  previously  to  thoroughly  heat  the  entire  body. 


ORIFIOIAL    SURGERY.  609 

In  entering  the  water  the  patient  should  first  step  into  the  tub, 
then  immerse  his  hands,  then  the  arms,  then  wash  his  face, 
throwing  the  water  with  the  hand  or  a  large  sponge  over  the 
front  of  the  body,  and  then  lie  down  in  the  water  just  long 
enoungh  to  be  completely  covered  by  it.  The  colder  the  water 
the  better.  Thirty  seconds  or  one  minute  is  ample  time  to  ac- 
complish this.  The  patient  should  be  quickly  clothed,  and  in- 
dulge in  sufficient  exercise  to  establish  a  healthy  glow  through- 
out the  entire  body.  The  cold  dip  or  the  shower  bath  should 
not  be  used  in  weak  persons,  as  the  failure  to  establish  a  suf- 
ficient degree  of  reaction  would  be  detrimental,  and  might  be 
dangerous.  Beyond  these  directions  you  are  respectfully  re- 
ferred to  Father  Kneipp,  as  his  simple  and  plain  presentation 
of  this  interesting  and  important  subject  seems  to  be  the  most 
condensed  and  practical  yet  put  in  print. 

PHYSICAL  TRAINING. 

That  systematic  physical  training  is  capable  of  rendering 
valuable  aid  in  the  emancipation  of  the  race  from  the  thraldom 
of  disease  is  unquestionably  true.  Doctors  know  it,  and  the 
whole  world  knows  it ;  and  that  the  world  is  tired  of  its  weak- 
ness and  of  its  sickness,  and  of  supporting  its  doctors  for  pur- 
poses of  bodily  patchwork,  and  proposes  to  take  the  matter  as 
much  as  possible  into  its  own  hands  and  work  out  its  own  sal- 
vation is  clearly  demonstrated  by  the  universal  movements  in 
the  direction  of  all  forms  of  athletics.  Baseball,  football, 
cricket,  lawn  tennis,  bicycle  riding,  the  establishment  of  multi- 
tudes of  gymnasiums,  all  speak  in  no  uncertain  voice  of  a  pro- 
found and  universal  tendency  to  the  re-establishment  of  true 
manhood  and  womanhood.  Health,  like  disease,  is  contagious, 
and  a  vigorous  and  well-balanced  physique  is  conducive  to  the 
establishment  and  practice  of  wholesome  mental  and  moral 
conditions  upon  which  the  escape  of  mankind  from  the  hands 
of  the  doctors  depends,  and  to  a  greater  extent  than  has  hith- 
erto been  appreciated.  While  a  human  being  can  continue 
thinking  and  feeling  in  accordance  with  well-established  laws 
of  life,  the  physical  health  is  assured  so  that  physical  training 
acts  first  upon  the  body,  and  through  this  upon  mental  anc| 


610  ORIFICTAL    SUBGERY. 

moral  processes,  which  in  turn  invigorate  the  body.  It  does  not 
follow  from  this  that  professional  athletes  are  ideal  specimens 
of  mental  and  moral,  as  well  as  physical,  perfection.  On  the 
contrary,  they  are  too  frequently  examples  of  very  question- 
able characters ;  and  no  wonder.  From  an  orificial  standpoint, 
they  belong  to  the  great  class  of  the  untrimmed,  and  are  still 
in  possession  of  the  inherited  and  acquired  forms  of  local  irri- 
tation. These  various  forms  of  irritation — the  long  foreskins, 
the  short  fraenums,  the  narrow  meatuses,  the  pockets  and  pa- 
pillae, the  fissures  and  hemorrhoids,  the  adherent  hoods  of  cli- 
torises and  irritable  hymens,  and  stenosed,  catarrhal  and  dis- 
placed uteri — are  perpetually  whispering  unwholesome  sug- 
gestions, and  an  increase  in  physical  vigor  simply  adds  ve- 
hemence to  these  morbid  propensities,  instead  of  serving  as  an 
added  force  in  the  direction  of  self-conquest.  The  acquisition 
of  physical  strength  is  merely  the  accumulation  of  power  which 
simply  propels  one  in  whatever  way  he  is  inclined  to  go.  For 
this  reason  one  should  surely  be  started  in  the  right  direction 
before  the  propelling  forces  of  life  are  greatly  increased.  Ori- 
ficial pruning,  or  at  least  examination  and  treatment,  if  neces- 
sary, until  ideal  local  conditions  are  secured  and  the  soul  is 
free  from  the  perpetual  suggestions  which  come  from  abnormal 
orifices,  is  first  in  order,  and  then  with  natural  tendencies  in 
the  direction  of  correct  living — for  spiritual  health  is  just  as 
natural  as  physical  health — a  perfect  physical  development, 
such  as  can  be  obtained  by  well-known  processes  and  appli- 
ances, will  simply  constitute  a  strong  fortress  of  defense 
against  the  invasion  of  disease  and  death.  Sexuality  is  one  of 
God's  greatest  gifts  to  man  and  is  essential  to  human  health, 
happiness  and  progress.  Sensuality  is  its  perversion  and  coun- 
terfeit, is  fed  by  morbid  physical  conditions,  and  is  responsible 
for  so  much  of  the  pain  and  sorrow,  and  the  various  forms  of 
sickness  known  as  crimes  and  all  their  attendant  consequences, 
to  say  nothing  of  the  multitudes  of  physical  diseases  for  which 
it  is  responsible,  that  its  cure  has  become  a  necessity.  To  ac- 
complish this  local  repair  is  first  demanded,  after  which  must 
follow  the  general  building  up. 


OEIFICIAL  SUEGEEY.  611 

HYPNOTISM. 

An  additional  power  of  service  in  the  extermination  of 
sensuality  is  hypnotism.  This  statement  is  based  upon  the 
assertions  of  Dr.  Cocke,  of  Boston,  who  is  not  only  an  experi- 
enced hypnotist,  but  an  able  physician  and  an  honorable  man, 
alive  to  the  weaknesses  and  necessities  of  the  sick,  and  intelli- 
gent in  the  application  of  remedies  for  their  relief.  He  re- 
ports that  it  is  frequently  necessary  in  the  cure  of  chronic 
cases  to  free  them  from  sensual  suggestions  by  which  they  are 
beset  involuntarily,  and  that  this  can  be  accomplished  under 
hypnotic  influence.  It  would  surely  interest  the  profession  if 
Dr.  Cocke,  or  some  one  equally  experienced  in  this  matter, 
would  tell  in  just  what  hypnotic  state  he  places  his  patient 
when  he  makes  the  suggestion  which  liberates  him  from  the 
slavery  of  sensuality.  Those  who  have  studied  Hudson's  book 
entitled,  "The  Law  of  Psychic  Phenomena"  will  remember  his 
clearly  expressed  analysis  of  the  objective  and  subjective 
minds,  and  his  explanation  of  all  hypnotic,  somnambulistic  and 
spiritual  phenomena,  upon  the  hypothesis  that  they  are  merely 
various  forms  of  subjective  activity,  attained  by  securing  the 
quiescence  of  objective  processes.  As  the  objective  mind  in- 
habits the  cerebro-spinal  system  and  the  subjective  the  sympa- 
thetic, this  simply  means  that  in  such  conditions  the  cerebro- 
spinal  ceases  to  dominate  the  sympathetic,  and  the  sympathetic 
is  controlled  by  the  cerebro-spinal  system  of  the  operator.  If 
this  be  true  the  science  of  hypnotism  is  yet  very  young,  and 
we  have  much  to  hope  from  it. 

Here  is  a  fact,  for  instance,  which  may  some  time  be  taken 
advantage  of.  An  anesthetic  paralyzes  the  cerebro-spinal  sys- 
tem much  after  the  same  manner  as  is  accomplished  by  hyp- 
notism, and  in  doing  this  the  patient  passes  through  different 
stages,  more  or  less  clearly  defined.  And  as  the  different  stages 
are  almost  identical  with  those  secured  by  hypnotism  when 
carried  to  the  point  of  complete  anesthesia,  why  should  it  not 
be  possible,  if  the  patient  be  taken  at  the  time  when  the  sug- 
gestions of  the  operator  will  be  most  powerfully  felt,  to  stamp 
the  subjective  mind  in  whatever  manner  desired.  In  other 


612  ORIF1CIAL  SUEGERY. 

words,  would  it  not  be  possible  to  correct  sensual  propensities 
when  the  patient  is  partially  anesthetized  with  as  much  cer- 
tainty and  satisfaction  as  could  be  secured  under  the  corre- 
sponding degree  of  hypnotic  sleep.  The  administration  of  an 
anesthetic  is  beneficial  in  most  forms  of  chronic  diseases,  es- 
pecially of  the  insane,  with  whom  some  form  of  sensuality  is 
a  prevailing  factor.  May  not  the  application  of  hypnotic  sug- 
gestion, applied  at  the  stage  of  anesthesia  at  which  outward  im- 
pressions exert  the  profoundest  influence,  prove  to  be  an  ad- 
ditional source  of  help  to  mind-bound  sufferers? 

EDUCATION. 

Education  will  also  be  required  to  lend  its  aid  in  the  solu- 
tion of  this  extensive  problem. 

In  this  age  of  individual  freedom  everybody  must  know 
why.  No  authority  is  influential  in  the  control  of  human  con- 
duct without  the  sanction  of  a  very  evident  reason,  and  this 
fact  involves  the  necessity  of  a  general  education  in  both  spir- 
itual and  physical  anatomy  and  physiology.  This  subject  is 
too  broad  to  be  even  epitomized  in  the  present  connection,  and 
the  mere  mention  of  it  by  title  must  suffice  for  our  present 
purpose.  But  educational  forces  are  at  work  and  the  light  is 
dawning,  and  before  the  sun  sets  upon  your  career  and  mine, 
such  progress  will  have  been  made  in  the  eradication  of  sensu- 
ality from  mankind  as  to  gladden  our  hearts  at  the  success  of 
the  campaign  in  which  orificial  surgeons,  from  a  physical 
standpoint,  are  the  pioneers. 

CHAPTER  LXXXIII. 


TISSUE  READING  FROM  AN  ORIFICIAL  STANDPOINT. 


E.   H.   PRATT,   M.   D. 


Most  of  the  animals  and  plants  that  have  lived  on  the 
earth  have  bequeathed  their  bodies  to  the  winds,  waves,  and 
soil,  and  in  these  common  burial-places  all  material  relics  of 
individuality  have  been  lost.  The  earth's  atmosphere  is  im- 


ORIF1CIAL  SURGERY.  613 

\ 

pregnated  with  the  gaseous  emanations  of  decomposing  forms 
which  life  has  assumed  and  afterward  abandoned.  The  waters 
of  the  earth  contain  in  solution  the  soluble  elements  of  dis- 
integrated shapes.  The  extensive  areas  of  settled  dust  that  are 
so  widely  spread  over  the  surface  of  the  earth  stand  for  the 
non-volatile,  insoluble  part  of  the  ashes  of  the  departed. 

But  although  the  winds  and  waters  and  farm-lands  are 
such  common  graveyards  that  they  tell  no  tales  of  individual 
existence,  nevertheless  some  specimens  of  almost  every  form 
of  plant  and  animal  life  have  been  preserved  in  rock-forma- 
tions and  in  coal-fields,  so  that  the  science  of  geology  has  been 
able  to  furnish  us  with  a  more  or  less  accurate  history  of  the 
evolution  of  life  in  its  various  forms  as  it  appeared  from  time 
to  time  on  the  surface  of  the  earth. 

It  is  much  the  same  with  the  human  body.  As  thoughts 
and  feelings  have  taken  on  cell-life  and  afterward  abandoned 
their  habitations,  all  that  is  gaseous  of  these  remains  has  been 
exhaled  by  the  breath  and  insensible  perspiration.  The  soluble 
parts  of  the  dead  cells  have  been  washed  away  by  the  sweat 
and  the  urine,  and  the  non-volatile  and  insoluble  portions  of 
the  devitalized  cells  are  carried  by  the  peristalsis  of  the  body 
into  the  alvine  canal  and  constitute,  with  the  unabsorbed  por- 
tion of  the  food,  the  steady  stream  of  fecal  matter  which  is 
systematically  evacuated  throughout  the  life  of  the  individual. 
But  the  gaseous,  liquid  and  solid  funeral  trains  of  the  body 
are  but  poor  tale-bearers  of  the  life  of  the  soul.  They  are  but 
plebian  graveyards,  whose  monuments  are  so  insignificant  as 
to  be  unsatisfactory  for  historical  purposes. 

But  the  various  bodily  tissues  do  not  always  readily  yield 
up  their  dead,  and  so  many  cells  of  every  variety  of  structure 
become  entangled  and  petrified  in  their  hard  and  horny  parts 
that  it  is  quite  possible  for  a  careful  observer  to  read  in  them 
with  more  or  less  accuracy  the  story  of  the  life  whose  petrified 
remains  nature  has  thus  carefully  preserved.  The  bones  have 
their  story  to  tell,  the  arteries  and  nerves  and  various  internal 
organs  are  record  sheets  which  can  be  read  when  brought  un- 
der the  scrutiny  of  a  trained  observer,  and  the  muscles,  mucous 
membranes  and  skin  are  equally  rich  in  historical  lore. 


614  ORIFICIAL  SURGERY. 

For  generations  doctors  have  searched  the  body  for  spots 
that  were  too  red  or  too  pale,  have  felt  all  over  it  for  places 
that  were  too  hot  or  too  cold,  too  hard  or  too  soft,  or  too 
prominent  or  too  deficient.  They  have  listened  for  sounds 
that  are  too  loud  or  too  faint,  or  too  harsh  or  too  smothered, 
every  one  of  the  deviations  from  the  normal  standard,  by  the 
aid  of  whatever  sense  they  were  diagnosed,  being  the  result  of 
the  more  or  less  extensive  accumulation  of  the  body's  dead 
cells.  Auscultation,  percussion,  palpitation,  and  inspection 
have  done  continuous  duty  throughout  the  history  of  medicine 
in  diagnosing  and  locating  the  ash-heaps  and  burial-mounds 
and  funeral-caves  into  which  the  body's  expiring  cells  have 
been  carried  and  deposited  by  the  streams  upon  whose  bosom 
all  bodily  commerce  is  carried  on.  Even  laymen  continually 
employ  their  powers  of  observation  to  tell  them  whether  it  is 
well  or  ill  with  the  souls  about  them. 

The  elasticity  or  steadiness  of  the  gait,  the  grace  or  awk- 
wardness of  the  general  bearing,  the  sweetness  or  harshness, 
the  friendliness  or  the  pathos,  the  bravery  or  the  cowardice,  or 
the  cruelty  of  the  voice,  and  every  other  fact  and  circumstance 
that  can  be  observed  by  their  various  senses,  are  constantly 
studied  to  ascertain  the  state  of  life  or  death  of  their  kinsmen. 
The  face,  too,  is  a  signboard,  which  everybody  glances  at,  not 
only  for  items  of  current  interest  in  soul-life,  but  also  for  the 
purpose  of  historical  investigations.  Laymen  are  more  or  less 
accomplished  tissue  readers,  and  expert  phrenologists,  physiog- 
nomists, and  palmists  find  abundant  occupation,  because  by 
reading  the  story  of  the  life  as  it  has  engraved  itself  in  tissue 
construction  they  are  able  with  more  or  less  accuracy  to  fore- 
cast the  possibilities  and  probabilities  of  the  future.  From 
what  has  been  ascertained  from  bodily  relics,  they  can  foretell 
history.  There  are  surface-markings  which  stand  for  every  va- 
riety of  thoughts  and  emotions  indulged  in,  and  by  applying 
the  well-known  laws  of  cause  and  effect,  they  are  able  to  con- 
clude with  the  certainty  of  logical  deductions  what  is  yet  to 
be  expected. 

But  the  establishment  of  the  orificial  philosophy  has  in- 
troduced to  the  world  a  new  variety  of  tissue  readers,  whose 


OKIFICIAL  SUKGERY.  615 

achievements  promise  to  be  more  interesting  and  important  to 
the  race  than  any  of  their  predecessors.  The  universal  fact 
that  the  condition  of  an  organ  expresses  itself  at  its  mouth 
furnishes  a  key  to  organic  history  and  deep-seated  tissue-read- 
ing by  which  the  book  of  life  can  be  opened  and  its  pages  read 
with  startling  fullness  and  accuracy.  Pale  mouths  tell  of 
cowardice  and  discouragement  and  despair,  and  the  consequent 
hunger  and  starvation  typified  by  anemia  of  the  organs  they 
serve.  Bright  red,  irritable  mouths  are  the  termini  of  organs 
that  are  themselves  in  an  excitable  and  irritable  condition. 
Dark  purple,  congested  mouths  bespeak  organs  clotted  with 
blood  stagnation,  implying  disturbed  functions,  which,  if  con- 
tinued, inaugurate  any  of  the  changes  which  have  their  incipi- 
ency  in  an  engorged  condition  of  stagnant  blood.  Atrophied 
mouths  guard  the  entrance  to  organs  which  are  atrophied, 
while  hypertrophied  outlets  indicate  a  hypertrophied  condi- 
tion of  the  parts  they  are  connected  with. 

There  is  an  exception  which  is  sometimes  to  be  taken  to 
every  one  of  these  statements.  It  is  where  there  has  been  a 
metastasis  of  anemia,  or  irritability,  or  congestion,  or  atrophy, 
or  hypertrophy,  from  an  organ  to  its  mouth.  In  such  cases  the 
condition  of  the  organ  is  to  be  read  by  contraries.  The  diag- 
nosis of  this  condition  many  times  implies  a  deep  appreciation 
and  insight  into  the  underlying  principles  of  action  of  the  indi- 
vidual, in  addition  to  the  employment  of  every  possible  means 
of  physical  diagnosis. 

But  the  greatest  service  which  the  orificial  philosophy  has 
bestowed  upon  mankind  consists  in  the  impulse  which  has  been 
given  the  medical  profession  to  carry  into  practical  applica- 
tion the  knowledge  of  which  it  is  already  possessed  concerning 
the  function  of  the  sympathetic  nerve.  For  generations  stu- 
dents of  medicine  have  been  taught  that  the  peristalses  of  the 
body  were  accomplished  by  involuntary  muscular  fibres  under 
the  domination  of  the  sympathetic  nerve.  And  they  have  been 
taught  also  the  meaning  of  peristalsis,  and  given  to  understand 
that  all  the  solids,  liquids,  and  gases  of  the  body  are  propelled 
along  their  various  channels  from  their  source  to  their  desti- 
nation by  this  action.  They  have  been  told  also  that  the  sexual 


616  ORtFlOlAL  SURGERY. 

organs  are  responsible  to  this  same  nerve  for  their  vitality 
and  the  performance  of  all  their  functions.  But  such  knowl- 
edge has  not  heretofore  been  taken  advantage  of,  and  students 
of  medicine  have  been  told  to  go  the  all-important  step  further 
and  study  the  waste  and  repair  of  the  sympathetic  nerve  as  a 
means  of  practical  importance  in  the  healing  of  the  sick. 

Knowing  the  fact  that  the  entire  bodily  commerce  was 
dependent  upon  sympathetic  nerve  force,  their  sin  of  omission 
has  been  great,  for  they  have  concerned  themselves,  alas !  too 
little  about  ways  and  means  of  economizing  the  expenditure  of 
this  force,  and  restoring  it  when  exhausted.  Their  efforts  at 
bodily  patchwork  have,  therefore,  been  exceedingly  lame  and 
unsatisfactory,  and  their  ability  to  re-establish  the  general 
bodily  vigor,  so  essential  to  all  re-building,  has  resulted  in  an 
ignominious  failure. 

I  am  well  aware  of  the  serious  nature  of  this  charge 
against  the  medical  profession.  I  have  no  disposition  to  be- 
little them  or  call  them  names.  I  know  their  labors  in  the  cause 
of  humanity  have  been  indefatigable.  I  know  that  they  have 
not  only  been  earnest  workers,  but  honest  ones,  and  although 
lives  have  been  lost  that  a  greater  knowledge  than  they  pos- 
sessed would  have  saved,  and  although  sickness  still  remains  a 
common  lot  of  mankind,  while,  in  a  large  percentage  of  cases 
at  least,  it  is  now  no  longer  necessary,  the  doctor  who  has  not 
been  able  to  cure  his  cases  throughout  all  time  has  suffered 
more  than  the  cases  themselves,  and  I  have  no  feeling  for  him 
but  that  of  the  tenderest  sympathy  and  consideration.  But, 
nevertheless,  the  accusation  that  the  medical  profession  is  der- 
elict, in  this  matter  of  the  appreciation  of  the  uses  and  abuses 
of  the  sympathetic  nervous  force,  is  true.  He  has  lost  his  sleep, 
his  rest,  his  comfort,  his  peace  of  mind,  as  well  as  of  body,  and, 
in  most  cases,  his  life.  His  best  service  has  oftentimes  been  the 
poorest  appreciated.  For  his  successes  he  has  been  poorly 
paid;  for  his  failures  he  has  been  too  severely  punished.  Nev- 
ertheless he  has  been  illogical,  and  has  not  made  sufficient  use 
of  the  knowledge  at  his  command,  and  the  only  way  in  which 
he  can  in  any  degree  compensate  the  world  for  his  great  crime 
of  omission  will  be  for  him  to  snap  the  bands  of  prejudice  that 


OEIFICIAL  SUEGERY.  617 

have  bound  him,  break  loose  from  the  thraldom  of  tradition, 
dispel  his  fear  of  so-called  authority,  cultivate  his  reason  and 
observation,  and  stimulate  his  self-reliance.  It  is  not  necessary 
for  him  to  study  harder,  but  think  more;  not  to  accumulate 
more  facts,  but  to  digest  those  already  in  his  possession.  He 
must  cease  propagating  mere  dogmatism  and  become  a  logical 
and  consistent  free-thinker,  fearing  not  men,  but  only  God  and 
his  own  conscience,  and  by  living  up  to  the  light  he  has  pre- 
pared himself  for  the  reception  of  still  greater  light. 

In  any  factory  run  by  the  force  of  steam,  a  waste  of  the 
steam  necessarily  decreases  the  power.  Steam  must  not  only 
be  manufactured,  but  it  must  be  boxed,  condensed,  held  tight, 
so  that  its  power  of  expansion  may  be  conveyed  by  pipes  to 
the  places  where  its  judicious  expenditure  will  make  the  wheels 
go  round.  In  a  corresponding  manner  is  the  sympathetic  nerve 
force  the  bodily  steam.  When  its  reservoirs  leak,  its  power  is 
correspondingly  depleted,  and  all  bodily  functions  become  en- 
feebled, and  if  some  organs  are  weaker  than  the  others  their 
action  may  be  completely  suspended.  The  question,  then,  of 
properly  performing  bodily  functions  of  all  kinds,  is  one  of  vi- 
tality or  sympathetic  nerve  power. 

As  the  history  of  the  cerebro-spinal  activity  of  a  person 
can  be  read  in  the  tissues  of  the  face,  hands  and  feet,  so  the 
history  of  the  sympathetic  life  of  the  individual  is  disclosed 
to  the  orificialist  without  other  testimony  than  is  furnished  by 
the  pelvic  tissues  themselves.  Pale  orifices  tell  of  exhausted 
energies.  Tight  ones  bespeak  a  prodigal  expenditure  of  nerve 
force  in  sustaining  undue  muscular  tension.  Patulous  open- 
ings disclose  a  lamentable  condition  of  a  still  further  extrava- 
gance of  nerve  force,  even  to  the  point  of  nervous  bankruptcy. 
Hypersensitive  tissues  at  the  floor  of  the  pelvis  mean  morbid 
sensibilities  of  both  mind  and  body  in  all  forms  of  their  activ- 
ity, and  papillary  developments  signify  that  the  condition  of 
morbid  sensibility  has  been  so  long  established  as  to  have 
passed  all  mere  functional  derangement  to  organic  pathology. 
Hyperesthesia  and  anesthesia  of  the  lower  orifices  are  keys  to 
the  condition  and  conduct  of  the  entire  person,  and  bespeak 
universally  prevailing  qualities  of  habits  of  thought  and  feel- 


618  ORIF1CIAL  SURGERY. 

ing,  interpreting  which  in  the  knowledge  of  the  universal  law 
of  cause  and  effect,  the  past  conduct  of  the  person  can  be  read 
like  a  history,  its  present  attitude  diagnosed  with  accuracy, 
and  its  future,  if  the  conditions  remain  unchanged,  safely 
prophesied.  Hypertrophied  tissues  of  an  orifice  reveal  prodig- 
iality,  and  atrophied  ones  parsimoniousness.  So  can  what  is 
good  and  what  is  bad,  what  is  generous  and  what  is  stingy, 
what  is  honorable  and  upright  and  what  is  disgraceful  and 
scandalous,  what  is  trustworthy  and  substantial  and  what  is 
apprehensive  and  cowardly;  and  the  continuous  antitheses  in 
the  entire  list  of  human  qualities  and  characteristics  be  surely 
and  accurately  read  by  an  expert  observer  in  the  conditions 
presented  by  the  pelvic  organs  of  the  person.  It  is  not  always 
what  the  surgeon  does  to  the  patient,  but  how  the  patient  be- 
haves under  the  treatment,  that  settles  the  outcome  of  surgical 
procedures,  and  a  careful  inspection  of  the  pelvic  tissues,  by 
revealing  to  the  surgeon  the  patient's  principles  of  action,  will 
enable  him  to  prognose  the  success  or  failure  of  his  efforts  at 
repair.  The  index  of  the  state  and  habits  of  the  life  forces  in 
the  individual  as  evidenced  by  the  pelvic  tissues  is  therefore  an 
invaluable  means  of  diagnosis  in  all  surgical  procedure.  The 
pelvic  tissue  reader,  however,  has  one  great  advantage  over 
other  body  geologists.  His  field  of  observation  contains  many 
of  the  electrical  buttons  which  control  the  direction  of  life's 
energies,  and  regardless  of  the  conditions  encountered,  lives 
can  be  righted  and  habits  of  thought  and  feeling  transformed 
to  the  liking  of  the  operator  if  he  is  sufficiently  skilled  in 
manipulating  as  well  as  in  reading  pelvic  organs. 

There  is  no  part  of  the  human  body  whose  skillful  manipu- 
lation can  influence  the  issues  of  life  and  death,  with  all  their 
varying  shades  of  approach  and  departure,  at  all  commensu- 
rate with  those  of  the  pelvis,  for  it  is  here  that  sympathetic 
terminals  are  accessible,  it  is  here  that  messages  of  rebuke  or 
of  commendation,  of  punishment  or  of  encouragement,  can  be 
sent  tingling  to  the  sympathetic  nerve  centers,  and  from  these 
throughout  the  entire  organization  of  the  individual,  influenc- 
ing functions,  inspiring  emotion,  stimulating  thought  activi- 
ties, and.  distributing  whatever  messages  are  sent  along  the 


ORIFICIAL  SUBGEBY.  619 

wires  throughout  the  whole  being.  Messages  from  the  pelvic 
outlets  touch  the  heart  and  brain,  and  through  these  the  bodily 
economy,  more  directly  than  those  received  from  any  other 
source,  for  they  appeal  to  the  nervous  system,  which  never 
sleeps,  which  is  the  first  to  be  born  and  the  last  to  die,  and  in 
whose  keeping  rests  the  issues  of  life  and  of  sickness,  of  hap- 
piness and  of  misery. 

Orificial  tissue  reading  is  as  yet  in  its  infancy.  But  young 
as  the  science  is,  its  permanency  and  development  is  ensured 
by  its  value,  not  only  as  a  historian  of  life,  but  also  as  a  power 
in  shaping  its  course.  Facts  are  but  the  crystallization  of  forces, 
and  the  proposition  is  universal  in  its  application.  It  therefore 
applies  to  bodily  tissues.  And  by  a  knowledge  of  cause  and 
effect  the  conditions  in  which  organs  ar  efound  stand  for  indi- 
vidual characteristics  and  qualities.  They  are  but  habit  prod- 
ucts, and  can  be  easily  interpreted  by  those  who  have  a  suf- 
ficient knowledge  of  forces  and  their  effects  to  read  these  hand- 
writings of  life  upon  the  impressionable  walls  of  time. 

Because  orificial  sign-reading  furnishes  a  substantial  basis 
for  accurate  surgical  judgment,  it  is  an  art  well  deserving  an 
extensive  cultivation. 

CHAPTER  LXXXIV. 


PROSTATES  AND  WOMBS. 


F.    W.    MORLEY,    M.    D. 


Case  1.    During  the  month  of  January,  Prof. -,  aged 

68  years,  presented  himself  for  treatment  for  the  relief  of  a 
slight  irritation  of  the  bladder,  which  necessitated  his  urinating 
about  every  hour  or  two  hours.  He  declared  he  was  never  in 
better  health  and  spirits  and  was  about  to  go  to  a  distant  city 
to  fill  an  engagement  which  took  him  before  the  public  as  well 
as  before  large  classes  of  ladies.  Tt  was  on  this  account  that 
he  sought  relief  from  this  slight  bladder  irritation.  We  are 
taught  that  men  of  his  age  often — yes,  always  have  enlarged 


620  ORIFIOIAL  SURGEEY. 

prostates,  and  that  gradual  dilatation  by  means  of  the  passage 
of  graduated  steel  sounds  is  "good"  for  that  complaint,  so  a 
No.  11  Pratt  sound  was  passed  to  the  prostate,  which  gave 
much  resistance  and  pain;  and  the  sound  was  removed,  fol- 
lowed by  a  gush  of  blood.  The  whole  man  seemed  to  have 
been  shocked,  and  although  he  said  nothing,  he  looked  every- 
thing. Within  two  hours  he  was  attacked  with  violent  sci- 
atica (left),  pain  running  to  heel  and  terminating  in  outer 
maleolus  where  the  cellular  tissue  became  very  much  injected, 
obliterating  all  anatomical  points.  A  violent  chill  of  three 
hours,  vomiting,  dysuria,  every  five  to  fifteen  minutes,  extreme 
pallor,  in  fact  the  nerves  of  animal  life  seemed  to  have  been 
suddenly  paralyzed.  He  was  weak,  listless,  indifferent,  apa- 
thetic, could  scarcely  speak  above  a  whisper.  This  last  feature 
was  very  marked  after  recovery  was  quite  well  established,  and 
exceedingly  annoying,  as  when  in  health  he  has  a  superb  voice. 
This  falling  to  pieces  process  went  on  for  several  days  when  re- 
covery was  established,  which  was  slow  indeed.  After  he  was 
able  to  be  about,  the  frequency  of  urination  was  not  lessened 
until  1  had  acted  upon  a  suggestion  given  me  by  my  esteemed 
friend  Dr.  Francis  D.  Holbrook,  of  Chicago,  and  given  the 
prostate,  which  was  as  large  as  my  fist,  a  thorough  daily  mas- 
sage. From  the  first  the  patient  was  relieved  and  used  to  say 
to  me  every  day,  "Doctor,  you've  hit  it  this  time." 

Case  2.  On  the  day  following  the  first  examination  of 
Prof.  -  — ,  Miss  -  -  presented  herself  for  the  relief  of 
metrorrhagia  of  ten  years'  standing.  A  steel  sound,  No.  11, 
was  passed  with  difficulty  along  the  cervico-uterine  track ;  al- 
most immediately  she  screamed  with  pain  in  left  leg  following 
the  course  of  the  sciatic,  down  to  the  heel — she  suffered  the 
most  excruciating  pain.  After  a  few  minutes  she  got  one- 
quarter  grain  morphia  and  went  home  in  a  coupe ;  had  no 
further  trouble  except  a  course  of  morphia  nausea. 

Case  3.  Deacon  -  — ,  aged  50  (white),  contracted  gon- 
orrheal  urethritis  from  undue  exposure  to  the  person  of  one 
Miss  -  -  (colored).  A  wild  orchitis  ensued  and  the  poor 
old  fool  suffered  intensely,  a  suffering  which  his  long-drawn- 
out  prayers  failed  to  mitigate.  In  due  time  he  presented  the 


ORIF1CIAL  SURGERY.  621 

usual  gleety  discharge  and  complained  that  the  bladder  was 
entirely  unreliable  especially  in  church.  Rectal  examination 
revealed  a  nodular  gland  the  size  of  an  orange,  the  left  lateral 
lobe  being  largest.  Massage  cured  the  ' '  everlasting  drop, ' '  the 
irritable  bladder,  restored  him  to  his  church  work,  and  I  am 
told  by  those  in  authority  that  the  deacon  never  prayed  bet- 
ter, his  voice  never  rang  out  clearer  than  since  he  had  the 
grippe  (?). 


SECTION  XI. 


After-Treatment 


ORIFICIAL    SURGERY.  625 


CHAPTER  LXXXV. 


IMPORTANCE  OF  AFTER-TREATMENT  IN  ORIFICIAL 

SURGERY. 


H.    A.    SHERWOOD,    M.    D. 


Probably  in  no  other  class  of  surgical  work  does  the  care- 
ful after-treatment  of  our  cases  demand  attention  for  so  long 
a  time,  as  in  orificial  surgery ;  and  the  neglect  of  such  continued 
treatment  is,  undoubtedly,  the  cause  of  many  failures  and  dis- 
appointments to  the  patient  as  well  as  the  surgeon.  When  we 
stop  to  consider  that  in  nearly  all  cases  of  those  who  resort  to 
this  method,  the  patient  has  been  a  chronic  sufferer,  has  been 
the  rounds  among  physicians,  and  tried  various  methods,  it  is 
not  strange  that  continued  after-treatment  is  of  vital  import- 
ance, if  we  are  to  be  successful. 

This  statement  is  undoubtedly  one  which  will  be  accepted 
by  you  as  a  body  of  orificial  surgeons,  without  a  dissenting 
voice.  But  to  impress  upon  the  minds  of  our  patients  the  ne- 
cessity of  after-treatment,  in  the  way  of  dilatation  of  the  lower 
orifices,  the  use  of  electricity,  massage,  hot  and  cold  water, 
rectal  flushings,  etc.,  is  a  thing  not  so  easily  accomplished.  It 
is  difficult  to  make  them  understand  how  the  use  of  dilators 
for  the  uterus,  rectum,  and  urethra  can  possibly  relieve  disor- 
dered conditions  of  other  parts  of  the  body.  This  fact  was 
forcibly  brought  to  my  mind  recently  while  dilating  the  lower 
orifices  of  an  insane  man,  for  whom  I  had  amputated  a  pendu- 
lous scrotum  and  operated  for  hemorrhoids.  He  said  he  did 
not  see  how  it  was  going  to  help  his  head  to  have  his  rectum 
and  urethra  stretched  twice  a  week,  and  he  was  getting  tired 
of  it.  I  finally  compromised  matters  with  him  by  sending  him 
to  Dr.  Sawyer's  Sanatorium  at  Marion,  Ohio,  where  I  felt  sure 
the  orificial  methods  would  be  continued  in  the  most  thorough 
manner. 

It  is  difficult  for  a  general  practitioner,  who  has  a  busy 
practice,  to  devote  the  necessary  time  to  the  after-treatment 


626  ORIFldAL  SURGERY. 

of  his  orificial  cases,  and  I  think  it  is  best,  when  the  patient 
becomes  discouraged,  to  send  him  away  if  possible  where  he 
can  have  the  benefit  of  a  change  of  scenery  and  the  various 
methods,  of  local  treatment  to  be  found  in  private  hospitals. 
In  my  experience  the  majority  of  patients  think  they  must 
notice  a  marked  bhange  as  soon  as  the  operation  is  performed ; 
and  when  they  do  not,  it  is  difficult  to  hold  them  long  enough  to 
follow  out  the  necessary  after-treatment. 

In  cases  of  sexual  neurasthenia  of  young  men,  I  have 
seldom  failed  to  get  satisfactory  results  in  those  cases  where 
the  patients  presented  themselves  regularly  and  for  a  proper 
length  of  time,  for  dilatation  after  the  primary  work  of  cir- 
cumcision. So  marked  has  been  the  difference  in  results  be- 
tween those  who  did  and  those  who  did  not  follow  out  the 
after-treatment,  that  I  have  adopted  a  rule  of  explaining  to 
each  patient  the  necessity  of  following  up  the  treatment ;  and 
those  who  will  not  promise  to  do  so,  I  do  not  urge  to  be 
operated. 

The  use  of  rectal  dilators,  either  with  or  without  hot  or 
cold  water,  has  been  practiced  and  followed  by  good  results  in 
the  hands  of  so  many  orificial  surgeons,  that  the  theory  of  Dr. 
Pratt,  that  this  mild  form  of  treatment  is  applicable  to  a  cer- 
tain class  of  weak  and  nervous  persons,  who  will  not  submit  to 
more  radical  measures,  is  well  established.  In  this  class,  too, 
the  treatment  must  be  long  continued  to  insure  satisfactory 
results. 

The  point  that  I  wish  to  make  in  this  brief  paper  then  is, 
that  whatever  we  do  along  the  line  of  orificial  work  must  be 
followed  up  with  the  same  earnestness  of  purpose  wkich  we 
possess  at  the  time  we  do  the  primary  work,  fully  believing 
that  this  is  the  only  way  to  derive  the  full  benefit  of  orificial 
work. 


ORIF1CIAL  SURGERY.  667 


CHAPTER  LXXXVI. 


AFTER  CARE 


E.    Z.    COKE,    M.    D. 


I  have  a  few  suggestions  to  offer  to  those  who  are  just  be- 
ginning to  do  orificial  work  and  to  those  who  have  experienced 
some  trouble  in  obtaining  satisfactory  results — both  local  and 
general — from  the  work. 

It  is  one  thing  to  do  a  skillful  surgical  operation,  and  it  is 
quite  another  to  have  beneficial  and  satisfactory  results  follow 
the  operation.  I  firmly  believe  that  a  great  deal  of  the  un- 
favorable criticism  we  have  had  to  face  is  largely  due  to  the 
fact  that  when  we  first  began  the  work  we  did  not  fully  realize 
the  importance  of  thorough  after  attention  and  treatment,  and 
we  have  had  to  learn  through  our  own  discouragements  and 
failures  the  necessity  of  following  up  these  cases  to  a  finish, 
whether  the  time  required  be  months  or  years.  After  the 
American  and  slit  operations  it  is  of  the  greatest  importance  to 
follow  the  case  with  thorough,  careful  dilatation,  trimming 
and  smoothing  (under  anaesthesia  when  necessary)  and  mas- 
saging of  the  parts  until  healthful  functions  are  restored. 

While  your  patient  is  receiving  this  care  keep  the  parts 
clean  and  use  colon  flushings  daily,  or  at  least  every  other  day. 
After  each  flushing  medicate  the  sigmoid  and  rectum  with  one 
or  two  ounces  of  olive  oil  and  phenol  sodique,  in  the  proportion 
of  one  drachm  of  phenol  sodique  to  one  ounce  of  olive  oil. 
There  are  a  number  of  other  good  remedies;  with  which  you 
are  all  familiar,  but  this  mixture  has  given  me  the  best  satis- 
faction of  any  one  remedy. 

As  a  rule  we  always  find  sigmoidal  trouble  in  these  cases, 
and  I  keep  up  this  plan  of  treatment  until  all  tenderness  in  the 
region  of  the  sigmoid  is  gone,  and  the  stools  have  a  natural  ap- 
pearance instead  of  being  a  mixture  of  balls  and  slimy  mucus. 
You  will  find  that  if  you  neglect  to  treat  the  sigmoid  you  will 
not  cure  these  cases,  and  the  time  to  treat  them  is  while  you 


628  OBIPICIAL  SURGERY. 

have  them  in  bed  and  under  your  control.  They  can  easily  be 
taught  to  follow  up  this  plan  of  treatment  at  home. 

Some  of  my  experience  in  rectal  work  has  been  gained  in 
the  Northern  Indiana  Prison,  where  I  have  been  consulting 
physician  and  surgeon  for  the  past  twelve  years.  The  prison 
hospital  is  by  no  means  a  sanitarium;  the  surroundings  are 
about  as  unhygienic  as  they  can  be  and  admit  of  the  possibility 
of  recovery,  and  if  there  are  any  trained  nurses  in  the  institu- 
tion they  did  not  go  there  voluntarily. 

Experience  has  taught  me  to  use  fine  silk  and  silk-worm 
gut  in  all  my  work.  I  have  entirely  given  up  the  use  of  catgut 
in  any  part  that  cannot  be  made  absolutely  aseptic  and  kept  so. 
I  can  then  use  such  local  measures  as  I  see  fit  without  danger 
of  the  sutures  softening  and  breaking  down — permitting  the 
tissues  to  become  infected,  suppurate  and  retract. 

Even  where  the  tissues  are  very  soft  from  old  inflamma- 
tory action,  the  silk  is  more  reliable  and  less  likely  to  pull  out. 

[We  now  have  catgut  prepared  to  last  a  sufficient  number  of 
days  for  union  to  take  place. — Ed.] 

With  the  use  of  a  two  or  four  per  cent,  solution  of  co- 
caine, there  will  be  little,  if  any,  pain  when  the  sutures  are  re- 
moved. 

I  use  hydro-naphthol  gauze  and  powder  in  place  of  iodo- 
f orm  (when  I  have  occasion  to  use  this  form  of  dressing) ,  with 
just  as  good  results  and  without  the  disagreeable  features  of 
iodoform.  If  from  any  cause  the  wound  breaks  down,  allowing 
the  mucous  membrane  to  retract  sufficient  to  permit  the  for- 
mation of  extensive  cicatricial  tissue  in  the  wound  surface, 
the  best  plan  is  to  make  the  wound  aseptic,  freshen  up  the  sur- 
face, dissect  the  mucous  membrane  free,  and  then  suture  as  in 
the  first  place.  This  will  save  you  a  great  deal  of  time  and 
trouble,  and  save  your  patient  much  pain  and  inconvenience. 

In  the  cervix  operation,  I  always  use  the  silk-worm  gut 
sutures,  leaving  a  long  end  on  each  side,  which  I  knot  together 
and  lay  above  the  uterus.  If  the  sutures  are  not  suppurating, 
I  prefer  to  leave  them  in  a  few  days  longer  than  the  prescribed 
time.  When  I  am  ready  to  remove  them  I  can  take  hold  of 
these  suture  ends  and  draw  the  uterus  down  easily,  bringing 


ORIFICIAL  SURGERY.  629 

the  sutures  to  view  and  permitting  their  easy  removal  without 
injury  to  the  wound.  In  these  cases  where  we  have  had  to  cut 
out  a  great  deal  of  cicatricial  tissue,  in  the  way  of  plugs,  the 
work  is  bound  to  be  followed  by  contractions  of  the  organ. 
When  we  find  our  patient  beginning  to  experience  a  return  of 
the  old  symptoms,  mental  and  physical,  that  called  for  the  work 
in  the  first  place,  it  is  an  unfailing  sign  that  she  is  suffering 
from  these  contractions,  and  we  must  put  the  patient  under 
an  anaesthetic,  dilate  the  cervix  thoroughly,  and  curette  the 
uterus  if  necessary.  Repeat  this  whenever  the  patient  appears 
to  be  falling  back  into  the  old  rut.  I  have  had  cases  which  re- 
quired this  to  be  done  on  an  average  of  twice  a  year  for  over 
three  years  before  a  cheerful,  hopeful,  mental  state  and  a  nor- 
mal physical  condition  was  assured.  Had  this  not  been  done, 
these  cases  would  have  been  worse  off  after  the  operation  than 
before;  and  would  not  people  have  been  justified  in  thinking 
and  saying  that  the  operation  was  injurious  rather  than  bene- 
ficial? 

Even  the  little  operation  for  phimosis  will  sometimes  be  a 
failure  for  want  of  attention  afterwards — this  can  also  be  the 
case  in  work  upon  the  clitoris. 

In  closing,  I  will  say,  never  undertake  to  do  orificial  work 
on  any  case  that  you  cannot  follow  to  a  finish,  either  personally 
or  through  some  competent  practitioner  who  is  in  full  sym- 
pathy with  this  work.  You  will  then  get  grand  results  in  cases 
that  would  otherwise  bring  discredit  upon  our  cause. 

CHAPTER  LXXXVII. 


AFTER-TREATMENT  IN  ORIFICIAL  SURGERY. 


FRANCIS   D.    HOLBROOK,    M.    D. 


The  preparatory  and  especially  the  after-treatment  in 
orificial  surgery  are  quite  as  important  as  the  operation.  The 
American  operation,  for  instance,  is  the  most  mechanical  and 
scientific  operation  for  the  excision  of  the  last  inch  of  the  rec- 
tum yet  devised,  and  can  be  made  to  leave  that  organ  as  serv- 


630  OK1F1CIAL  SURGERY. 

iceable  and  unobtrusive  as  a  normal  one.  Yet  how  it  has  been 
assailed  by  both  profession  and  laity,  because  it  is  not  always 
satisfactory!  And  why?  Because  we  have  not  followed  the 
work  to  a  finish. 

Simply  once  curetting,  packing  and  doing  other  orificial 
work  will  cure  only  about  fifty  per  cent,  of  the  cases  of  dys- 
menorrhea.  They  will  all  be  better  for  a  time,  but  it  does  not 
cure.  We  must  handle  them  again  and  again  to  attain  the  best 
results;  and  let  me  tell  you,  while  you  are  taking  good  care 
of  your  patient,  following  up  the  work  already  done  by  good 
after-treatment,  your  patient  will  not  want  to  go  off  to  another 
doctor,  and  you  can  follow  your  curable  cases  to  a  cure. 

Many  cases  of  locomotor  ataxia  can  be  cured,  and  the  ma- 
jority benefited,  not  by  orificial  surgery  alone,  but  with  ori- 
ficial operations  and  the  other  methods  known  to  the  profes- 
sion, such  as  electricity,  massage,  baths,  drugs,  etc. 

With  many  of  our  patients  the  preparatory  treatment  is 
the  operation,  but  there  is  no  question  but  treatment,  to  get 
the  patient  in  condition  for  the  surgical  work,  is  of  great  value. 

If  we  are  to  work  upon  the  uterus,  either  curette  and  pack, 
repair  a  cervix,  perform  hysterectomy,  or  anything  in  the  line 
of  uterine  work,  and  the  organ  is  big  and  flabby  or  eroded,  a 
great  deal  can  be  done  to  lessen  the  size  and  tone  it  up,  and  get 
it  in  better  condition  by  douches,  tampons,  replacing  if  it  be 
out  of  place,  and  attention  to  the  bowel,  using  either  cathartic 
or  enema.  When  patients  come  to  the  hospital,  where  it  is  pos- 
sible for  them  to  be  treated  a  day  or  two  before  the  operation, 
we  put  them  through  the  following  course :  Give  them  a  thor- 
ough tub-bath,  scrubbing  with  soap  and  brush,  then  a  salt  glow, 
an  enema  of  about  15  drops  of  turpentine  to  a  gallon  of  water, 
or  use  hamamelis,  or  anything  of  that  kind,  and  have  the  bow- 
els move  thoroughly;  if  a  woman,  give  a  vaginal  douche,  1  to 
4000  bichloride,  inject  a  little  bovinine  into  the  vagina  to  re- 
move secretions,  then  irrigate,  then  equal  parts  of  peroxide 
and  water,  and  irrigate  again;  the  vagina  to  be  thoroughly 
dried  with  gauze  sponges.  If  the  cervix  be  much  hypertro- 
phied,  we  insert  a  pledget  of  cotton  saturated  with  the  fol- 
lowing preparation : 


ORIFICIAL  SUEGERY.  631 

Oil  Eucalyptus,  2  drachms, 
Hamamelis,  4  ounces, 
Glycerine,  4  ounces. 

You  will  find  that  this  will  reduce  the  swelling.  It  is  a  good 
plan  to  put  a  little  vaseline  on  the  tampon  to  make  its  removal 
easy.  We  repeat  this  local  treatment  daily,  have  the  bowels 
move  every  day,  and  continue  the  use  of  the  tampon  for  two 
or  three  days  previous  to  the  operation.  The  night  before  the 
operation  the  tampon  is  removed,  a  douche  is  given  and  the 
vagina  packed  with  iodoform  gauze  which  is  removed  the 
morning  of  the  operation. 

A  cathartic  should  not  be  given  under  thirty-six  hours 
before  the  operation;  an  anema  should  not  be  given  on  the 
morning  of  the  operation  or  immediately  before,  but  one  should 
be  given  the  night  before. 

It  is  our  practice  to  give  a  hypodermic  of  1-4  grain  of 
morphine  and  1-150  of  atropine  about  fifteen  minutes  before 
starting  the  anesthetic  for  operation  as  it  steadies  the  heart, 
takes  less  anesthetic  to  hold  the  patient  well  under,  and  when 
patient  awakes  after  the  operation  it  is  as  from  a  sleep  rather 
than  in  the  hysterical  condition  which  is  so  common  with  ether 
or  chloroform.  [H.  M.  C.  is  preferable. — Ed.] 

The  immediate  after-treatment  is  much  the  same  in  all 
varieties  of  the  work.  For  nausea  and  vomiting  immediately 
following  the  operation,  the  less  you  put  into  the  stomach  the 
quicker  relief  is  obtained.  All  the  drugs  in  the  Materia  Medica 
are  sometimes  unavailing.  Champagne,  sherry,  inhalation  of 
camphor  fumes,  vinegar  fumes,  hot  and  cold  milk,  water,  cof- 
fee, tea  and  a  host  of  other  things  have  all  been  given  with  va- 
riable success.  But  to  cure  the  vomiting  naturally  you  must 
reverse  the  peristalsis,  and  the  quickest  measure  for  that  is  to 
get  the  gases  to  go  down  by  the  use  of  a  catheter  in  the  rectum, 
or  an  enema  of  hot  water,  six  or  ten  ounces  with  ten  drops  of 
turpentine  in  it. 

Dr.  Bessey: — How  soon  after  the  operation? 

Dr.  Holbrook: — Immediately  after — for  instance,  if  your 
operation  is  either  rectal,  cervical,  or  on  the  abdomen,  and 


632  ORIF1CIAL  SURGERY. 

the  patient  vomits  more  than  ordinarily,  and  you  have  tried 
ice-bags  on  the  throat,  had  them  lie  on  the  back,  had  them  put 
the  head  down  ,given  them  morphine,  and  they  still  continue 
to  vomit  for  six  or  seven  hours,  I  would  suggest  that  you  use 
the  catheter — insert  it  in  the  bowel  and  you  will  find  it  lets 
off  a  large  quantity  of  flatus.  That  relieves  for  the  time  being. 
Should  the  nausea  return  then  I  suggest  that  you  throw  hot 
water,  plain  or  salt,  into  the  bowel  which  not  only  reverses  the 
peristalsis  but  relieves  restlessness. 

Dr.  Dunn: — How  soon  would  you  give  a  cathartic? 

Dr.  Holbrook: — Seldom  immediately  after  the  operation 
as  it  is  weakening.  They  have  got  all  they  can  do  to  revive 
from  the  operation. 

When  the  nausea  and  vomiting  continue  and  pain  is  felt 
over  the  abdomen,  you  should  not  feel  easy  about  your  case 
until  the  gases  have  passed,  else  you  may  have  peritonitis,  and 
you  will  check  but  few  cases  of  well  defined  peritonitis  that 
follow  an  operation.  If  your  patient  starts  in  with  fever, 
restlessness  and  pain,  and  the  gases  form,  you  insert  your  cath- 
eter and  draw  off  a  little  gas,  and  there  still  is  vomiting ;  your 
case  is  not  in  a  very  good  condition,  and  if  you  don't  relieve  it 
by  the  milder  measures  you  ought  to  give  a  full  enema ;  I  would 
use  two  quarts  to  a  gallon  of  water,  have  a  free  passage  from 
the  bowel.  If  you  can  take  them  in  that  stage  you  can  prevent 
the  peritonitis ;  but  if  not,  if  they  go  two  or  three  days  and  the 
fever  gets  a  hold,  tongue  a  dark  color,  restless  and  vomiting, 
and  the  vomit  is  black,  you  can  seldom  cure  them. 

Morphine  is  very  useful  immediately  following  these  ori- 
ficial  operations  as  it  abates  the  nerve-shock.  Of  course  in 
many  cases  it  is  unnecessary.  I  have  never  seen  any  harm 
come  from  its  moderate  use  and  I  have  seen  a  great  deal  of 
good.  It  is  only  necessary  to  continue  it  through  the  first  forty- 
eight  hours  usually.  Arnica  and  hypericum  have  both  been 
used  to  quiet  the  pain  with  fairly  good  success,  but  nothing 
"gets  there"  like  the  morphine.  I  would  suggest,  especially 
after  the  American  operation  where  there  is  a  great  deal  of 
contracting  pain,  that  you  give  the  morphine,  give  it  in  quarter 
grain  doses ;  give  it  to  the  point  of  relief.  After  the  slit  opera- 


OBIF1CIAL  SURGERY.  633 

tion,  the  hot  compresses  against  the  rectum  will  relieve  the 
pain.  Tak  a  fold  of  a  piece  of  flannel  and  wring  it  out  of  hot 
water  and  put  it  against  the  buttocks  and  the  anus,  it  re- 
lieves the  pain,  reduces  swelling  and  stops  a  good  deal  of  the 
oozing. 

The  first  dressing  of  the  wound  is  iodof orm ;  subsequently, 
if  the  patient  objects  to  the  odor,  and  a  great  many  are 
nauseated  by  its  use,  we  change  to  either  aristol,  iodol,  quinine, 
acetanilid,  boracic  acid  or  bismuth.  We  prefer  to  dress  wounds 
dry,  especially  while  stitches  are  in  situ.  Then  apply  either 
iodoform  gauze  or  sterilized  dressing  and  bandage.  Douche 
twice  a  day  with  solution  of  either  boracic  acid,  carbolic  acid 
or  bichloride  of  mercury,  pledget  of  sterilized  gauze. 

Dr.  Bessey: — You  give  the  douche  right  along  after  the 
operation  ? 

Dr.  Holbrook : — Yes,  with  rectal  work,  and  forty-eight 
hours  after  uterine  work. 

A  Doctor: — Doesn't  that  soften  the  stitches? 

Dr.  Holbrook: — Not  if  dried  thoroughly. 

A  Doctor: — Wouldn't  it  be  better  to  use  silk  stitches? 

Dr.  Holbrook: — I  prefer  catgut.  Silk  sutures  have  to  be 
removed,  which  is  a  very  painful  operation.  The  catgut  will 
not  absorb  under  four  or  five  days  if  you  take  good  care  of  it, 
using  the  dry  dressing. 

When  the  uterus  has  been  curetted  and  packed,  the  pack- 
ing is  allowed  to  remain  in  the  cavity  from  twenty-four  to 
forty-eight  hours,  unless  patient  complains  of  great  pain,  and 
there  is  too  much  reaction.  Then  you  should  remove  the  pack- 
ing and  give  a  douche  even  as  early  as  three  or  four  hours  fol- 
lowing the  operation.  When  the  operation  is  trachelorraphy, 
at  the  time  of  the  operation  iodoform  gauze  should  be  inserted 
in  vagina ;  allow  to  remain  about  two  days,  then  renew  it,  but 
don't  pack  the  vagina  full.  Be  as  careful  as  possible  when  in- 
serting the  speculum,  as  opening  it  will  force  the  margins  of 
your  wound  apart. 

After  hysterectomy,  we  douche  with  bichloride,  1  to  4000. 

With  celiotomies  and  vaginal  hysterectomies  nothing  is  al- 
lowed in  the  stomach  for  twenty-four  hours,  not  even  water. 


634  ORIFICIAL  SURGERY. 

After  that  time  coffee,  tea,  milk  or  broth  can  be  given  in  very 
small  quantities.  If  this  sets  up  vomiting  or  distress,  it 
should  be  discontinued  for  twenty-four  or  forty-eight  hours, 
then  by  that  time  you  will  probably  find  the  patient  in  a  con- 
dition to  retain  it.  In  the  meantime  feed  the  patient  by  way  of 
the  rectum,  using  either  bovinine  or  Murdock's  food,  milk  or 
any  nourishing  liquid  which  may  be  absorbed  readily  for 
nourishment. 

For  the  thirst  following  these  major  operations,  a  little  hot 
water  thrown  into  the  rectum  will  satisfy  quickly. 

Now  as  regards  the  first  and  subsequent  movement  of  the 
bowels  after  the  operation  on  the  rectum.  We  allow  the  bowel 
to  remain  inactive  for  four  full  days;  give  a  cathartic  on  the 
evening  of  the  third  day,  following  with  an  anema  the  fourth 
day. 

Dr.  Bessey: — What,  doctor? 

Dr.  Holbrook: — For  cathartic  compound  licorice  powder, 
Garfield  tea,  cascara  sagrada  and  salts  are  the  mildest  and 
most  effectual. 

Inactivity  of  the  bowels  for  three  or  four  days  is  attend- 
ed with  the  best  results  and  least  pain,  but  I  have  noticed  that 
those  patients  whose  bowels  move  three,  four  or  five  times  a  day 
immediately  following  operation,  from  chronic  diarrhea,  usu- 
ally make  quite  as  good  a  recovery  as  the  others.  The  first 
movement  of  the  bowels  is  sometimes  associated  with  great 
pain  and  often  a  chill,  so  you'd  better  have  somebody  with 
them.  If  patients  have  a  chill,  give  a  quarter  grain  of  mor- 
phine ;  this  will  stop  it  quicker  than  anything  else. 

You  will  have  to  use  a  catheter  in  ninety  per  cent,  of  the 
cases  of  orificial  work  for  a  few  days. 

Where  the  rectal  wound  is  slow  in  healing  use  such  stimu- 
lants as  hydrastis,  compound  tincture  benzoin,  carbolic  acid, 
sulphate  of  copper,  eucalyptus  or  quinine.  We  often  use  a 
rock  oil  called  "Jo-He."  It  allays  inflammation,  relieves  pain, 
and  is  excellent  in  healing  wounds. 

Patient  should  remain  in  bed  one  week  after  the  slit  opera- 
tion; with  the  American  operation  one  ought  to  lie  in  bed  ten 
days  or  two  weeks  to  get  the  best  union,  the  best  results,  and 


OBIPICIAL  SURGERY.  635 

less  trouble  afterward.  With  a  uterine  operation  where  you 
have  curetted  and  repaired  the  cervix,  it  is  unsafe  to  allow  the 
patient  up  in  less  than  ten  days.  Dr.  Morley  spoke  of  letting 
them  up  the  next  day;  I  think  he  had  reference  to  repairing 
the  cervix  by  simply  scraping  the  end  of  it  and  putting  in  a 
few  stitches — that's  all  right.  But  where  you  curette  a  uterus, 
put  in  packing  and  do  an  operation  that  will  take  ordinarily 
half  an  hour,  give  an  anesthetic  too,  and  then  allow  her  to  get 
up  the  next  day,  why,  I  think  it  is  very  unsafe  and  almost 
criminal.  (Applause.) 

I  once  repaired  a  cervix  and  perineum,  all  without  an  an- 
esthetic. I  packed  the  vagina,  and  told  the  woman  to  stay  in 
bed  a  week.  At  the  end  of  that  time  I  went  down  to  remove 
the  silver  stitches  and  found  her  sitting  up.  I  told  her  I  want- 
ed her  to  stay  in  bed  till  the  stitches  were  removed.  She  said, 
"I  have  been  up  every  day  since  you  were  here."  I  removed 
the  packing  placed  there  the  week  before ;  of  course  it  smelled 
simply  frightfully,  but  the  wound  had  healed  perfectly  and 
she  didn't  have  a  particle  of  trouble;  however,  I  don't  recom- 
mend this  method. 

After  vaginal  hysterectomy,  patients  may  get  up  in  two 
weeks,  providing  they  are  in  good  condition,  their  temperature 
has  been  normal  for  a  number  of  days,  appetite  and  sleep  has 
been  good  and  wound  healed ;  and  after  a  celiotomy  the  same 
rule  applies. 

After  ventral  fixation  the  person  should  lie  in  bed  from 
two  to  three  weeks,  and  the  stitch  which  fixes  the  uterus  to  the 
peritoneum  should  remain  in  a  week  to  two  weeks  according 
to  the  conditions.  If  the  wound  is  healthy  and  no  discharge  or 
redness  about  it,  there  is  no  reason  why  the  stitch  should  not 
remain  in  two  weeks.  There  is  scarcely  any  pain  with  ventral 
fixation,  or  with  laparotomy  wounds,  and  very  little  pain  with 
hysterectomy  by  the  Pratt  method.  The  pain  and  distress 
which  are  common,  I  think  come  from  the  accumulation  of 
gases.  I  have  noticed  that  there  is  less  pain  after  sewing  the 
wound  as  you  saw  it  done  today,  than  by  the  other  methods. 
In  doing  an  American  operation,  if  you  get  union  by  first  inten- 
tion you  will  find  a  distinct  line  of  demarkation  between  the 


636  ORIFICIAL  SUEGERY. 

mucous  membrane  and  the  skin  which  will  mark  the  location 
of  the  scar,  and  that  scar  will  contract  as  patient  gets  up  and 
goes  around ;  and  at  the  end  of  two  or  three  weeks  or  a  month, 
perhaps,  you  will  be  surprised  to  see  that  the  anus  is  not  any 
bigger  than  the  end  of  a  pencil  and  there  is  a  hard  cicatricial 
scar.  The  scar  should  be  clipped  in  four  places,  not  in  the  an- 
terior or  posterior  parts  of  the  wound,  but  just  at  the  left  and 
right,  either  side  of  the  median  line !  insert  the  speculum  and 
dilate  the  rectum  gently.  This  was  our  method  of  correcting 
the  stricture  by  taking  a  patient  ten  days  or  two  weeks  after 
the  American  operation.  When  the  scar  begins  to  contract,  if 
you  will  practice  massage  on  this  scar  and  the  buttocks,  using 
the  Jo-He  as  a  lubricant,  you  will  be  surprised  at  the  ease  you 
will  give  the  patient,  and  the  rapidity  with  which  the  scar  will 
absorb.  The  lack  of  control,  either  of  the  feces  or  of  gases,  is 
not  due  to  a  ruptured  sphincter  in  ninety-nine  cases  out  of  one 
hundred,  it  is  simply  due  to  the  cicatricial  contraction — they 
cannot  contract  that  scar,  because  it  is  non-elastic.  You  must 
absorb  the  scar  before  you  get  full  control  of  the  sphincter. 

Sometimes  in  healing  you  will  find  a  pouting  condition  of 
the  mucous  membrane;  clip  that  off  with  the  scissors,  there  is 
no  pain. 

You  will  sometimes  operate  for  an  enlarged  prostate,  per- 
haps doing  the  American  operation,  perhaps  doing  the  slit 
operation,  possibly  circumcision  ;pass  sounds,  clip  the  meatus 
and  clip  the  frenum.  The  patient  will  be  immediately  relieved 
by  the  operation ;  then  in  about  ten  or  twelve  days  the  old 
symptoms  will  return ;  you  will  find  the  prostate  as  large  as 
before  if  not  a  little  larger.  To  reduce  that  congestion  use 
massage ;  put  the  finger  in  the  rectum,  outline  the  prostate  and 
do  the  same  work  on  the  prostate  that  you  do  on  a  uterus  or 
cicatricial  scar;  in  five  minutes  time  you  can  reduce  that  con- 
gestion so  that  the  prostate  is  normal  in  size.  Repeat  the  mas- 
sage every  day  or  two  according  to  the  symptoms  manifest. 
There  is  art  in  this  business  as  well  as  science ;  insert  the 
finger  in  the  rectum  easily,  gracefully  and  nicely ;  massage  with 
skill  and  you  will  do  no  harm,  but  if  you  are  rough  you  will  do 
more  harm  than  good. 


ORIFICIAL  SURGERY.  637 

Subsequent  to  this  work  the  passing  of  sounds  is  bene- 
ficial and  should  be  used  for  the  enlarged  prostate  about  two 
or  three  weeks  after  the  operation.  Heat  the  sound  with  hot 
water  first,  insert  in  the  urethra,  let  it  remain  about  ten  min- 
utes, then  put  sound  in  cold  water  and  insert  in  uretha  again 
and  remove  immediately ;  to  massage  while  sound  is  in  situ  is 
very  beneficial. 

Regarding  the  after-treatment,  so  long  as  your  patient  is 
improving,  let  him  alone.  Perhaps  they  come  to  you  with 
dyspepsia,  headache,  or  similar  troubles,  and  you  operate  on 
them;  they  are  better  from  the  work,  recovering  nicely  from 
the  operation  and  feel  better  in  every  way.  Let  them  alone, 
don't  dilate  them  or  do  anything  of  that  kind.  It  is  all  right 
to  attend  to  the  local^wound,  but  don't  begin  the  use  of  sounds 
or  rectal  dilatations  or  anything  of  that  kind  to  tone  them  up 
and  make  them  better  until  they  come  to  a  stand-still,  then  use 
sounds,  dilatation,  etc. 

A  Doctor: — Suppose  the  mucous  membrane  draws  up  and 
granulates  after  the  American  operation? 

Dr.  Holbrook : — In  the  American  operation  where  the  mu- 
cous membrane  breaks  loose,  I  would  handle  that  wound  the 
same  as  any  other  wound,  curette  it,  use  the  dry  dressing,  or 
stimulate  it  with  boracic  acid,  benzoin  or  tincture  of  hydras- 
tis.  If  the  gut  has  retracted  all  around,  broken  loose  entirely, 
and  if  there  is  a  raw  surface  and  it  causes  distress,  you  must 
put  your  patient  to  sleep  again,  pull  the  retracted  gut  down 
again,  sever  the  longitudinal  fibres  that  pull  it  up  and  stitch  as 
before.  You  may  use  a  suture,  the  same  as  you  saw  in  the  ven- 
tral fixation;  take  two  buttons,  put  one  button  in  the  rectum 
and  the  other  on  the  buttock,  about  an  inch  out  from  margin  of 
anus,  with  stay  suture.  Then  if  you  will  dress  the  wound  as 
before  you  will  get  good  results. 

Dr.  Walker: — One  question  in  regard  to  the  after-treat- 
ment of  the  rectum.  In  the  classes  heretofore,  I  have  noticed 
that  the  roll  of  cotton  used  was  about  eight  inches  long  and  as 
large  as  the  wrist,  introduced  into  the  rectum,  called  the  rectal 
packing,  to  remain  from  twenty-four  to  forty-eight  hours.  I 
notice  now  that  the  rectal  packing  is  about  the  size  of  two 


638  ORIFICIAL  SURGERY. 

fingers.  I  want  to  ask  if  there  are  any  bad  results  from  the 
packing,  or  is  it  to  prevent  the  escape  of  the  gases?  I  want 
to  ask  why  the  change  of  treatment  ? 

Dr.  Holbrook : — Early  in  the  work  the  packing  was  pretty 
large,  I  remember,  and  was  hard  to  insert  sometimes;  the  size 
now  is  suitable  for  the  majority  of  the  cases.  In  the  after- 
treatment  of  the  sigmoid,  for  constipation  especially,  we  use 
the  Kelly  sigmoidoscope  or  the  old  Brinkerhoff  speculum, — 
through  which  we  can  pass  medicated  cotton  or  wool  into  the 
sigmoid.  For  constipation  we  have  used  all  sorts  of  prepara- 
tions on  this  packing  by  way  of  medication,  glycerine,  ham- 
amelis,  Jo-He,  etc. ;  have  obtained  the  best  results  in  constipa- 
tion from  the  use  of  inspissated  ox  gall;  saturate  the  pledget 
of  cotton  with  it  and  insert  it  high  up  in  sigmoid;  this  over- 
comes the  constipated  habit  of  the  bowels  quicker  than  any- 
thing  else  I  know  of. 

A  Doctor: — You  mean  temporarily? 

Dr.  Holbrook: — No;  the  bowels  are  often  sluggish  after 
the  orificial  work  has  been  done,  and  only  need  a  little  treat- 
ment to  complete  the  cure. 

A  Doctor: — You  don't  refer  to  the  habit  of  constipation. 

Dr.  Holbrook: — Yes,  when  the  local  condition  has  been 
relieved  by  operations  and  the  constipation  continues,  it  is 
usually  due  to  a  sigmoid  condition,  which  needs  treating  be- 
fore the  case  will  clear  up. 

Dr.  Sharp: — I  understand  Dr.  Holbrook  to  say  that  the 
most  important  thing  to  do  in  severe  vomiting  is  to  establish 
downward  peristalsis.  If  that  is  so,  why  does  he  give  large 
doses  of  morphine,  which  paralye  the  bowels  and  lock  up  the 
secretions  ? 

Dr.  Holbrook: — I  don't  think  it  does,  doctor.  After  an 
operation,  an  orificial  one  for  instance,  where  the  nerves  are 
all  shaken  up,  the  morphine  will  quiet  them  down,  prevent  the 
vomiting,  keep  them  quiet,  allow  the  system  to  swing  back  into 
tone  and  get  back  its  equilibrium.  I  don't  think  a  quarter  of 
a  grain  of  morphine  will,  to  any  great  extent,  check  the  action 
of  the  bowels;  I  don't  think  it  will  stop  the  secretions  or  par- 
alyze them  to  any  great  extent.  The  shock  of  the  rectal  work 


ORIFICIAL  SURGERY.  639 

will  often  stop  the  secretions  by  setting  up  contractions.  The 
morphine  overcomes  this  condition. 

Dr.  Morley: — We  don't  use  morphine,  after  perhaps  about 
twelve  hours,  in  some  cases  not  so  long.  We  find  some  cases  of 
the  American  operation,  which  is  always  the  most  painful, 
where  perhaps  one  injection  will  answer  for  several  hours; 
other  cases  have  injections  from  half  an  hour  to  an  hour 
apart  for  two  or  three  times. 

Dr.  Sharp : — The  reason  I  spoke  of  it,  I  saw  Dr.  Senn  last 
summer  at  the  St.  Francis  Hospital,  and  in  the  majority  of  op- 
erations he  gave  no  morphine.  I  asked  why  not;  and  he  said  it 
locked  up  the  secretions,  and  he  found  it  was  a  bad  thing  to  do. 

Dr.  Holbrook: — Were  they  rectal  operations? 

Dr.  Sharp: — No,  they  were  laparotomies. 

Dr.  Carriker : — In  some  cases  after  the  American  operation 
in  nervous  patients,  there  seems  to  be  pain  close  on  to  the  ex- 
ternal nerves,  there  is  spasmodic  contraction  of  the  sphincter. 
I'd  like  to  ask  the  doctor  what  he  does  in  those  cases  to  keep 
the  sphincters  quiet? 

Dr.  Holbrook : — The  sphincters  will  contract  spasmodically 
for  a  day  or  two  after  the  operation.  The  only  thing  I  have 
found  that  will  stop  these  contractions  is  the  morphine.  I 
think  the  hot  water  and  hot  fomentations  would  stop  it,  but  I 
don't  like  the  hot  fomentations  and  moisture  where  there  are 
stitches,  so  I  use  morphine. 

Dr.  Cole : — In  speaking  about  relieving  the  contraction  of 
the  sphincters,  I  can  speak  from  experience.  I  know  that  the 
hot  fomentations  will  relieve  it;  I  am  sure  of  it,  and  that  is 
one  of  the  reasons  why  I  advocate  the  use  of  the  silk  suture — 
that  you  can  use  as  much  moisture  about  the  wound  as  you  like 
and  it  saves  the  use  of  morphine.  I  know  it  will  do  it,  because 
I  have  used  it  ever  since  I  commenced  closing  the  wound  with 
silk.  In  some  cases  I  use  four  interrupted  silk  sutures  and 
close  it  with  catgut,  because  the  four  will  support  it  if  the  con- 
tinuous suture  should  break  down ;  but  the  hot  water  will  re- 
lieve that  spasmodic  contraction. 

Dr.  Sharp : — I  would  like  to  ask  the  doctor  why  he  objects 
to  giving  morphine? 


640  ORIFICIAL  SURGERY. 

Dr.  Cole: — On  general  principles;  I  believe  the  patient  is 
better  off  without  it,  if  possible  to  get  along  without  it ;  no  ob- 
jection to  it  if  it  has  to  be  used. 

Dr.  Dunn  (Titusville)  : — I  have  a  suggestion  to  offer  in 
this  matter.  When  I  operated  for  these  troubles  I  immediately 
gave  my  patient  ferri  phos.,  which  is  an  excellent  remedy  to 
control  fever,  inflammatory  action  and  the  like,  and  I  don't 
know  of  any  remedy  that  reaches  so  far  in  the  direction  to 
overcome  shock  and  tendency  to  fever  as  that  drug,  ferri  phos., 
from  3x  to  6x.  When  I  have  had  that  spasm  of  the  rectum  to 
annoy  me  I  have  used  hot  fomentation  with  magnesia  phos.  dis- 
solved in  it  and  it  will  almost  entirely  control  that  spasmodic 
action  of  the  sphincters.  Such  has  been  my  experience.  I  have 
not  used  morphine — I  have  no  objection  to  its  use  but  I  have 
been  an  allopathic  physician  for  thirty  years  and  I  try  to  es- 
cape anything  connected  with  the  palliative  mode  of  treatment 
of  disease ;  I  seek  a  remedy  and  in  this  ferri  phos.  and  magnesia 
phos.  I  find  the  remedies  for  this  trouble. 

Dr.  Erni : — In  my  first  cases  I  used  ferri  phos. ;  it  cured 
the  spasmodic  action  of  the  rectum,  but  introducing  the  rectal 
plug  relieves  it  quicker  and  more  effectually  than  anything 
else  I  know  of. 

Dr.  Clark: — In  the  line  of  treatment  after  the  operation 
there  is  one  thing  I  would  like  to  mention  in  regard  to  the 
enema;  flaxseed  is  the  most  serviceable,  being  very  soothing 
and  beneficial.  Take  a  teacupful  of  the  seed,  tie  it  in  a  bag, 
boil  half  an  hour  in  water  and  it  is  ready  for  use. 

Dr.  Walker: — I  want  to  speak  one  word  with  regard  to 
the  hypodermic  use  of  morphine.  There  is  no  question  but 
the  morphine  in  hypodermic  doses  is  good,  and  my  practice  is 
this :  if  the  patient  is  in  pain  give  him  a  quarter  of  a  grain  of 
morphine  with  the  atropine  hypodermically,  but  if  not  in  pain 
but  restless,  etc.,  give  morphine  an  eighth  to  a  half  grain.  I 
do  not  think  bad  results  can  come  from  it. 

[To  prevent  vomiting  following  anesthesia  thoroughly 
wash  out  the  stomach  with  tube  before  the  patient  recovers 
consciousness,  or  just  before  putting  to  bed.  Also  when  nan- 


ORIFICIAL  SURGERY.  641 

sea  is  first  manifested  give  a  glass  of  water  with  two-thirds  of 
teaspoonful  of  bicarb,  soda.  I  have  found  codeine  preferable 
to  morphine. 

Where  there  is  anuria,  spartein,  given  hypodermically  will 
be  found  very  effective ;  also  the  colon  douche  of  warm  normal 
salt  solution,  and  hot  fomentations  to  the  back  over  the  kid- 
neys.— Editor.] 


SECTION  XII. 


Some  After-Thoughts, 
Warnings,  and  Helpful  Hints, 


OKIF1CIAL  SUEGERY.  645 


CHAPTER  LXXXVIII. 


SOME    AFTER-THOUGHTS,    SUGGESTIONS,    WARNINGS 
AND  HELPFUL  HINTS. 


BY    THE    EDITOR. 


The  entire  field  of  the  Orificial  Thought  is  so  well  covered 
by  the  preceding  chapters  that  there  is  but  little  left  to  be  sup- 
plied by  the  editor.  , 

He  makes  no  claim  of  originality  to  the  matter  here  pre- 
sented, as  some  of  it  is  embraced  in  the  body  of  the  book  in  ar- 
ticles by  other  writers.  Most  of  it  has  been  gleaned  from  Dr. 
Pratt 's  clinics,  lectures  and  writings,  verified  where  possible, 
and  placed  here  for  its  utility  and  convenience. 

Remember  in  using  Bovinine  for  a  dressing  that  it  will 
digest  catgut. 

Do  not  use  continuous  sutures  where  there  is  a  circle,  as 
around  the  anus  or  prepuce. 

Be  careful  not  to  over-dilate  the  rectum.  You  may  tear 
the  posterior  fibers  of  the  sphincter  muscle. 

In  making  up  your  diagnosis  and  applying  therapeutic 
measures  do  not  forget  that  the  irritation  of  an  organ  begins 
at  its  mouth. 

From  a  pathological  standpoint  the  rectum  and  uterus  are 
twins;  where  you  find  chronic  trouble  in  one  the  other  will 
also  need  your  attention. 

Blood  stasis  is  the  beginning  of  all  pathology. 

Be  very  careful  in  dilatating  the  rectum  of  children  and  old 
people — use  caution,  go  slowly,  or  you  may  regret  it. 

That  which  can  flush  capillaries,  deepen  or  stop  res- 
piration, is  a  measure  of  great  potency  for  good  or  evil,  as  it 
may  be  used. 

Consumptives  are  sexual  perverts,  pointing  to  sympathetic 
nerve  waste :  a  valuable  index  to  the  treatment  required. 


646  OKiPICIAL  SURGERY. 

Always  search  for  sympathetic  nerve  waste  in  chronic 
diseases. 

In  Orificial  Therapeutics  the  central  idea  is  to  secure  un- 
embarrassed sympathetic  nerve  terminals  at  the  pelvic  outlets. 

Almost  every  case  of  insanity  of  single  women  will  have 
erosion  of  the  cervix. 

When  your  patient  is  irritable,  cross,  cranky,  there  is 
rectal  trouble;  when  depressed,  has  the  blues,  there  is  catarrh 
of  the  colon. 

Many  of  your  old  cases  of  gleet  that  have  long  resisted 
medication  can  be  at  once  cleared  up  by  doing  proper  orificial 
work  on  the  rectum. 

Irritation  at  one  end  of  a  tube  is  often  reflexed  to  the 
other,  as  pin  worms  at  the  anus  will  make  the  lips  pale  and  the 
nose  itch.  This  might  suggest  appendectomy  in  some  rectal 
troubles. 

In  the  male  the  condition  of  the  inner  surface  of  the  lips 
of  the  meatus  is  an  index  to  the  condition  of  the  prostate  gland, 
as  the  tongue  is  to  the  stomach. 

A  good  operation  for  laceration  of  the  cervix  involves  the 
removal  of  all  the  scar  tissue.  Those  cases  that  heal  without 
treatment  are  the  ones  that  cause  trouble. 

Rectal  pockets  and  papillae  are  liable  to  return  after  re- 
moval and  may  require  three  or  four  sittings  to  eradicate  them. 

In  doing  slit  work  for  hemorrhoids,  removing  pockets  or 
papillae,  to  avoid  hematocele,  dilate  the  rectumafter  you  have 
done  your  work,  and  not  before,  unless  you  are  going  to  put 
in  stitches. 

In  trachelorrhaphy,  when  making  the  first  incision  to  ex- 
pose the  scar  tissue,  remember  that  you  are  holding  the  uterus 
down,  or  you  may  cut  too  high  and  cut  off  the  uterine  artery. 

The  greatest  resussitant  from  whiskey,  morphine,  chloral, 
chloroform — from  any  narcotic,  shcxck,  or  collapse  from  any 
cause,  is  an  appeal  to  the  last  inch  of  the  rectum,  by  dilatation 
and  heat. 

Your  fingers  or  Pratt 's  rectal  speculum  will  give  you  di- 
latation but  not  heat.  The  hot  water  plug  will  provide  both  at 
the  same  time.  This  is  a  hollow  metal  plug  or  dilator  with 


ORIFICIAL  SURGERY.  647 

two  short  tubes  at  its  base.  Place  a  syringe  tube  on  one  and 
a  waste  rubber  tube  on  the  other.  Insert  into  the  rectum  and 
let  the  hot  water — 115  degrees  to  120  degrees — flow  from  the 
syringe  through  this  dilator  into  a  slop  pail. 

When  your  patient  is  cyanotic,  lungs  filled  with  mucous 
and  rattling  in  the  throat,  you  will  be  astonished  and  gratified 
at  the  result  of  this  measure.  It  will  also  promptly  relieve  the 
worst  cases  of  asthma.  Every  doctor  should  have  a  hot  water 
plug. 

The  blood  stream  is  that  which  does  all  bodily  repair, 
heals  all  diseases,  removes  all  pathology,  induces  growth  and 
sustains  life.  How  important  that  we  study  and  use  every 
measure  that  can  improve  the  circulation  and  flush  capillaries. 

Irritation  in  the  last  inch  of  the  rectum,  if  on  the  an- 
terior surface  will  affect  the  sexual  organs;  if  on  the  posterior 
surface,  the  spine ;  if  on  the  lateral  surface,  the  sciatic  nerve 
and  legs.  Spasmodic  action  of  the  internal  sphincter  lowers 
the  vitality  of  the  whole  body. 

To  diagnose  a  fistula  where  you  can  find  no  opening,  in- 
sert the  forefinger  into  the  rectum  and  with  thumb  and  finger 
carefully  palpate  the  perianal  tissue.  You  can  feel  the  "pipe" 
or  tract  of  the  fistula. 

Where  there  is  an  external  opening  and  you  can  not  find 
the  internal — apparently  external  blind — inject  peroxide  of 
hydrogen  into  the  external  opening  and  through  the  open 
rectal  speculum  watch  for  the  foaming  into  the  gut. 

Where  the  rectum  is  impinged  by  the  uterine  fundus  it 
would  be  worse  than  useless  to  remove  pockets  and  papillae  or 
hemorrhoids  without  relieving  the  impingement.  Your  rectal 
work  without  relieving  the  impingement  would  invite  and  ag- 
gravate hemorrhoids. 

In  some  cases  of  exaggerated  retroflexion  or  retroversion 
of  the  uterus,  pressing  on  the  hypogastric  plexus  of  nerves, 
thereby  causing  difficult  or  loud  breathing,  the  uterus  must 
be  lifted  up  into  position.  If  there  is  a  tuberculous  tendency 
this  condition  spells  doom  if  permitted  to  remain.  General  ori- 
ficial  work  without  replacing  the  uterus  would  not  relieve  her ; 


648  ORIF1CIAL  SUKGERY. 

it  would  be  fanning  the  feeble  flame  of  vitality  while  a  stream 
of  water  is  constantly  pouring  over  the  fuel. 

Where  the  patient  has  little  vitality  and  rectal  dilatation 
produces  great  effect  on  the  respiration  at  its  initiation  but 
meets  with  no  response  by  repetition,  you  may  know  he  is  on 
the  verge  of  the  precipice  of  death.  Look  out !  be  very  careful, 
or  your  patient  may  slip  through  your  fingers.  Gently  and 
cautiously  do  a  little  dilating  and  remove  what  nerve  impinge- 
ment he  will  bear,  wait  five  days  or  more,  when  he  will  take 
the  anesthetic  kindly  and  hold  up  well  under  the  operation. 

In  performing  colporrhaphy,  for  systocele,  before  suturing 
the  vaginal  flaps,  peel  these  flaps  of  the  vaginal  mucous  mem- 
brane so  that  they  will  slide  over  the  muscular  coat  of  the 
bladder  for  three  quarters  of  an  inch.  Otherwise  the  stitches 
will  be  strained  by  a  tight  suture  line,  leaving  cicatricial  tis- 
sue as  a  thorn  in  the  flesh  at  the  base  of  the  bladder.  This 
little  point  is  the  door  between  success  and  failure  in  operating 
for  cystocele. 

Orificial  work  may  arouse  a  sleeping  demon  or  a  lot  of 
little  devils.  This  is  more  liable  where  the  patient  has  not 
taken  a  course  of  preparatory  treatment.  It  may  so  stir  up  the 
waste  and  excretory  organs  that  they  will  become  clogged.  In 
an  old  chronic  it  may  awaken  the  evil  spirit  of  his  malaria  so 
that  he  periodically  marches  his  progeny  of  chills  and  fever 
through  the  body;  or  the  old  suppressed  gonorrhea  may  burst 
the  confining  dam  and  overflow  the  banks.  It  is  well  to  warn 
the  patient  that  a  repetition  of  his  old  trouble  may  take  place. 

The  great  majority  of  chronics  have  a  loaded  colon — an 
impaction;  consequently  there  is  auto-infection  from  absorp- 
tion. There  is  poison  in  the  kitchen.  You  must  clear  this 
colon,  open  the  emunctories  and  start  the  funeral  trains. 
Throw  eight  to  sixteen  ounces  of  olive  oil  into  the  colon  and 
follow  with  all  the  soapsuds  the  bowel  will  hold.  Then  let 
him  evacuate  the  bowel.  To  the  soapsuds  may  be  added  one 
dram  of  ox  gall  or  half  a  teaspoonful  of  turpentine.  At  first 
repeat  this  every  day,  then  every  other  day,  then  twice  a  week. 
This,  and  this  only,  will  remove  the  fecal  matter  that  clings  to 


ORIFICIAL  SUEGEEY.  649 

the  lining  of  the  colon.  Also  flush  the  kidneys  with  normal  salt 
solution  thrown  into  the  colon  three  or  four  times  a  week. 

As  an  antiseptic  in  Orificial  Surgery,  both  as  a  dressing 
and  to  disinfect  the  field  before  operating,  I  have  found  soluble 
iodin  very  satisfactory.  I  wish  here  to  commend  the  prepara- 
tion known  as  lodum-Miller.  It  is  effective,  reliable  and  ready 
for  use.  It  is  soluble  in  water  but  free  from  water  and  alco- 
hol. I  have  no  financial  interest  in  it  nor  am  I  under  any  obli- 
gation to  the  proprietors. 

If  you  cannot  get  the  patient 's  permission,  or  her  condition 
contravenes  a  surgical  procedure  for  lifting  and  retaining  the 
uterine  fundus  from  its  backward  mal-position,  you  may  pack 
the  vagina  after  Pratt 's  method  with  excellent  results.  Pratt 's 
method  is  as  follows : 

Hook  a  tenaculum  into  the  anterior  lip  of  the  cervix  and 
drag  the  uterus  down,  pass  the  forefinger  as  high  up  on  the 
anterior  surface  of  the  neck  as  possible,  and  force  the  neck 
upwards  and  backwards.  The  fundus  following  the  curve  of 
the  sacrum  throws  the  uterus  forward.  The  tenaculum  holds  the 
cervix  down  while  the  pressure  of  tlie  finger  bends  the  middle 
of  the  uterus  backwards  toward  the  curve  of  the  sacrum.  You 
now  begin  the  packing  in  the  front  of  the  uterus  (not  behind, 
as  other  so-called  authorities  direct),  with  the  finger  and  ten- 
aculum holding  the  organ  in  place,  pack  first  in  the  middle, 
then  on  either  side,  and  repeat  in  this  manner  until  the  whole 
vagina  is  well  filled  with  gauze.  After  forty-eight  hours  take 
out  and  repack. 

SUBCUTANEOUS  OPERATION  FOR  VARICOCELE. 

Pratt 's  Method. 

Seize  the  lower  part  of  the  scrotum  with  the  thumb  and 
finger  and  palm  of  the  hand.  Secure  the  tissues  below  the 
cord.  Feel  your  way  along  until  you  come  to  a  part  that  is 
hard  like  a  knitting  needle;  that  is  the  vas  deferens.  Let 
that  and  the  spermatic  artery  slip  by,  retaining  all  else  between 
your  thumb  and  finger.  Now  with  a  needle,  threaded  with 
carbolized  catgut,  transfix  the  scrotum  by  passing  between  the 


650  ORIF1CIAL  SUBGEEY. 

vas  deferens  and  the  variococele.  Next  enter  the  needle  at 
the  same  point  where  it  came  out;  hug  the  skin  and  pass  on 
the  opposite  side  of  the  varicocele  from  the  other  suture,  and 
emerge  at  the  same  point  of  first  entrance.  Drawing  the  thread 
it  will  now  surround  the  veins  forming  the  varicocele  within 
the  scrotum.  The  same  suture  is  put  in  one  inch  above  this 
first  one.  Before  tightening  these  ligatures  hold  up  the  testi- 
cle and  milk  the  blood  out  of  the  veins  between  them.  Next 
tighten  the  ligatures  pretty  tight  and  hold  them  apart  so  tnat 
you  can  feel  the  bunch  of  tissues  that  have  been  isolated ;  take 
a  scalpel  and  subcutaneously  sever  the  veins  between  the  liga- 
tures, being  careful  not  to  wound  the  vas  deference  and  not 
cutting  the  skin  except  at  the  point  where  the  knife  entered. 
Cut  the  ligatures  short  and  pull  the  scrotum  over  them.  Re- 
covery is  rapid,  but  little  soreness,  and  there  will  be  no  pus. 

The  sexual  system  is  the  creative  force.  We  are  conceived 
and  born  through  it.  A  new  thought  is  creative  work  and  is 
born  through  the  sexual  system  just  the  same  as  a  new  baby. 
Great  artists,  poets,  orators,  inventors — those  who  do  creative 
work*  and  give  the  world  something  new,  are  strongly  endowed 
sexually.  Strong  sexual  endowment  is  a  fertile  field  for  new 
growths;  it  is  the  factory  where  new  things  are  made;  the 
foundry  where  new  ideas  are  molded.  The  prodigal  who 
spends  this  endowment  in  riotous  living  will  soon  find  him- 
self wallowing  in  the  mire  and  feeding  with  swine.  It  is  a 
hot  bed  that  may  produce  noxious  weeds,  or  rich  wholesome 
fruit. 

Metastasis,  with  its  marvelous  phenomena,  spreads  before 
us  a  great  map  for  our  careful  study  in  the  geography  of  Ori- 
ficial  Philosophy.  There  may  be  metastasis  from  within  out- 
wards and  from  without  inwards;  from  nerve  terminals  to 
nerve  centers,  and  from  nerve  centers  to  nerve  terminals ;  from 
skin  to  mucous  membrane,  and  from  mucous  membrane  to  skin  ; 
from  the  physical  body  to  the  emotional  and  intellectual  cen- 
ters— metastasis  in  every  conceivable  way.  From  a  rusty  nail 
in  the  foot  the  irritation  may  go  to  the  other  end  of  the  nerve 
and  produce  lockjaw  or  insanity.  The  foot  does  not  hurt; 
the  patient  can  walk  on  it.  If  you  have  metastasis  in  mumps 


ORIFICIAL  SUEGERY.  651 

the  irritation  leaves  the  upper  glands  and  moves  down  to  the 
sexual  organs.  In  other  words,  in  metastasis  there  is  a  drain- 
ing away,  a  leaving  the  primary  congestion  to  some  other  part. 
Following  exaggerated  hemorrhoids,  fistula  or  gross  pathology 
in  the  pelvis,  there  may  be  rheumatism,  dyspepsia,  asthma,  etc., 
etc.,  but  there  will  now  be  atrophy  where  there  was  congestion 
or  inflammation. 

The  class  of  cases  where  you  can  do  the  most  good  is  not 
the  one  where  you  find  gross  pathology  at  the  lower  openings, 
such  as  extravagant  hemorrhoids,  fistula,  etc.,  but  where  the 
patient  is  down  with  something  else — asthma,  rheumatism, 
neuralgia,  insanity,  headache,  some  chronic  trouble  that  does 
not  respond  to  other  measures  of  therapeutics.  The  patient  is 
not  conscious  of  any  rectal  or  pelvic  trouble.  But  here  you 
will  find  a  more  profound  condition  than  hypertrophy;  you 
will  find  atrophy ;  tissues  pale,  anemic ;  perhaps  a  small  meatus, 
short  frenum,  long,  tight  or  adherent  prepuce,  pockets  or 
papilla?  in  the  rectum,  an  impinged  clitoris,  etc.  This  is  the 
class  of  cases  where  this  work  will  do  wonders. 


Index. 


A    Chronic    Invalid 208 

Acne  in  Young  Men 591 

After-treatment    627 

After-treatment    629 

Anatomy    and    Physiology    of 

the  Eeetum   ." 250 

Anemia,    Headache    and    Neu- 
ralgia     172 

A  Plea   for  Orificial   Surgery.   55 

A  Plea  for  the  Insane 179 

Asthma    563 

A  Surgical  Talk  on  the  Orifices  19 


Bed   Wetting    60 

Birth  of  Orificial  Surgery 17 


D 


Dangers    and    Possibilities    of 

Orificial  Surgery 173 

Diarrhoea 581 

Dilatation    184 

Dilatation   of  the  Foreskin. .  .188 

Dilatation  of  the  Urethra 189 

Dilatation  of  the  Vulva,  Vag- 
ina and  Urethra 454 

Dropsy    193 

Dropsy    563 


E 


Epilepsy    586 


Capillary  Circulation   90 

Cerebro-Spinal      and      Sympa- 
thetic   Systems    92 

Cerebro-Spinal   System    93 

Cervix  Uteri    461 

Cervix  Uteri,  Amputation   of. 464 

Cervix    Uteri,    Lacerated 464 

Cervix  Uteri,  Strawberry  Ero- 
sion of    462 

Circumcision     392 

Circumcision     401 

Circumcision    of   Girls 482 

Clitoris,  Adhesions  of 491 

Constipation    578 

Constipation    584 

Constipation    and   Diarrhoea.  .581 


Female  Sexual  Organs 431 

Fibroids,  Uterine    172 

Fistula,    Rectal    328 

Fistula,   Eeetal    345 

Fraenum    408 

Functional  Disturbance   .       ..555 


G 


General  Practitioner  and  Ori- 
ficial Surgery  82 

General  Practitioner  as  Orifi- 
cialist  211 

Gynecological  Reflexes    495 


654 


INDEX. 


H 

Hallucinations  157 

Hay  Fever  157 

Heart  Disease  160 

Helpful  Hints  645 

Hemorrhoids  293 

Hemorrhoids  Acute  External. 297 

Hemorrhoids  Active  300 

Hemorrhoids  Chronic 298 

Hemorrhoids  External  300 

Hemorrhoids  Excision  of..... 302 
Hemorrhoids  Middle  Variety. 299 

Hemorrhoids  Passive  299 

Hemorrhoids  Slit  Operation 

for  306 

Hemorrhoids  Slit  Operation 

under  Cocaine  311 

Hemorrhoids  Treatment  of... 296 
Hemorrhoids  Treatment  of 

Middle  301 

Hemorrhoids  Treatment  of... 312 

Hiccough  595 

History  of  Orificial  Surgery. .  26 

Hypnotism  611 

Hystorectomy  Vaginal  466 

Hysterectomy  Vaginal  474 


Insanity    78 

Insanity    81 

Insanity    561 

Insanity    568 

Insomnia   .  566 


Lacerated  Cervix   157 

Laparotomy  and  Orificial  Phi- 
losophy    229 

Lowered  Vitality    551 

M 

Malaria    79 

Marasmus,  Dyspepsia  and   In- 
somnia        37 

Massage    198 

Meatus  and  Urethra,  Male... 407 

Mental   Healing    529 

Mental    Healing    543 

Methods  of  Operations   181 


N 

Nature  as  a  Surgeon   102 

Nerve  Distribution,  manner  of  101 

Nervous   Dyspepsia    72 

Nerve   Impingement    in    Surg- 
ery     216 

Neurasthenia     575 

Nipples  of  Nursing  Mother..  105 

O 

Orifieial  Methods  of  Cure 120 

Orificial  Philosophy   114 

Orificial  Reflexes  Clinically  Il- 
lustrated      155 

Orificial  Surgery 55 

Orificial  Surgery  61 

Orificial   Surgery,   a  Primitive 

Measure    173 

Orificial    Surgery — Fact,    Fad, 
or  Fancy 39 

P 

Papillae    274 

Paralysis    35 

Perineum — Repair  of    499 

Philosophy   of    Orificial    Surg- 
ery     122 

Pockets  and  Pupillae 118 

Pockets   and  Pupillae 250 

Prepuce   4U* 

Proof  of  Experience 202 

Prostate  Gland    418 

Prostates  and  Wombs 619 

R 
Rectal  Plugs  and  Tampons.. .  .199 

Rectal   Surgery    281 

Rectal    Surgery    and    General 

Surgery    242 

Reflexes  141 

Reflexes  an  Diagnosis 160 

Reflex   Neuroses    153 

Relation   of  the  Two   Nervous 

Systems   92 

Rectum  and  Anus 237 

Rectum   Exterpution   of 388 

Rectum  and  Sigmoid   365 

Rectum  Stricture  of    335 

Rectum  Toilet  of   247 

Rectum   Ulcers    of 335 

Rectum  and  Uterus 105 


INDEX. 


655 


Sexual  Habits  and  Necessities  601 
Sexual   Organs — Anatomy  and 

Physiology   of    387 

Sigmoid    365 

Sigmoid    369 

Sigmoid    372 

Sigmoid   Diseases  of    380 

Sigmoid  and  Rectum   365 

Skin   Lesions   and   Dropsy.  .  .  .564 

Sounds   .199 

Stricture   of   the   Rectum 33'5 

Suggestions    196 

Suggestive  Therapeutics 505 

Surgical  Judgment   171 

Surgical  Operations  by  Nature  102 
Sympathetic     Nerve — Charact- 
eristics of   106 

Sympathetic  System    95 

Sympathetic   Nerve   Terminals 
in   Women    ....  .  .444 


Technique  of  Orificdal  Surgery  165 

The  American   Operation 318 

The  American  Operation 320 

The     'Composite     Physological 

Man    87 

Tissue    Reading    612 

Tuberculosis   .34 


U 

Ulcers  of  the  Rectum. 


.335 


Vaginal  Hysterectomy   466 

Vaginal  Hysterectomy   474 

Varicocele    649 

Vaso-motor    Centres     129 

Vitality,  Lowered 551 

Vomiting,  Dyspepsia    161 

Vomiting,   Sympathetic    593 

W 

Water  a«  a  Therapeutic  Agent  197 
Why  this  Method  Cures  Chron- 
ic Diseases   133 


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PRINTED    IN    U.S.* 


CAT.   NO    24    161 


A  000502560 


WO  500 
D272  o 
1912 
Davson,  Benjamin  E 

Orificial  surgery;  its  philosophy, 
application  and  technique 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


UC   IRVINE    LIBRARIES 


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